Great New Book on the Back Pain Industry

80140100113640LHave any of you ever had back pain? Or maybe the question should be, have any of you never had back pain? Whatever the answer, I want to tell you about a book our series The Culture and Politics of Health Care Work at Cornell University Press has just published. It’s called Watch Your Back: How the Back Pain Industry Is Costing Us More and Giving Us Less by Richard A. Deyo. It is really really important, not only because it will help back pain sufferers figure out what to do – exercise, PT etc.—and what not to do– surgery etc. It will help those who deal with patients with back pain –MDs, PAs, NPs etc – arm themselves with the necessary scientific evidence to resist false fixes and treat back pain with real evidence based practice.   It will also add to the literature on the impact of financial incentives on treatment decisions in an increasingly market driven healthcare system in the US.

Deyo begins his book with an overview of the back pain industry and then, in subsequent chapters, looks at the kinds of treatments this industry – made up of device manufacturers, pharmaceutical companies, and, sadly, back surgeons and assorted other physicians who can’t seem to figure out whether the goal of medicine is to serve patients or enrich themselves. Deyo, who is a Professor Internal and Family Medicine at Oregon Health Sciences University has spent decades researching effective treatments for back pain. He and his colleagues published a study of the efficacy of TENS units for back pain. The study, which was published in the New England Journal of Medicine, found there was not much difference between use of TENS units and a placebo. That study got a lot of people mad at him. That was nothing like the firestorm that erupted when he and his colleagues received funding from the federal Agency for Health Care Policy and Research to consider the efficacy of spinal fusion surgery. Deyo was also on a panel that put out clinical guidelines around the treatment of low back pain and found that surgery was not a good option.

The North American Spine Society, made up largely of spine surgeons went ballistic. They lobbied Congress and almost got the agency killed. The Agency lived, but with less funding and it was no longer allowed to produce the kind of evidence based clinical guidelines that should, of course, guide practice.

In this book, which I was thrilled to edit, Deyo has targeted many other treatments. His book, which is masterfully written (I had to change barely a line) explores everything from the once vaunted treatment of bedrest to the overuse of spinal fusion therapies, TENS units, injections, painkillers, and other so-called silver bullets. Analyzing all of the research, he concludes that most are not useful and that exercise and PT are the most effective treatments.

Deyo’s book is, in the tradition of Jerome Kassirer’s On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health and others that have explored the corrupting influences of industry on physician practice. It does not, however, condemn all physicians for recommending treatments that may do more harm than good. Deyo understands that many physicians just want to help their patients who come to them in pain and begging for a “cure.” Some give in to the demand for a quick fix. Others are influenced by supposedly objective research that is, in fact, the product of industry’s successful efforts to seduce big name physicians into  promoting treatments of dubious value to the patient to their colleagues. Others see nails because they are equipped with very expensive hammers whose use garners them a tidy sum.

As I was editing the book, I kept feeling what I felt when I read Jerry Kassirer’s book On the Take. What chance does a patient have trying to figure out what to do when so many physicians are either misled by their colleagues or by their own self-interest?  Although Deyo’s book does not directly take this on, the book is yet another argument for jettisoning our fee-for-service system in favor of one that pays physicians salaries, thus protecting them from the dazzling blindness and moral amnesia that results when human beings are confronted with the temptations that big business parades in front of so many MDs – and increasingly PAs and NPs (their latest targets).

Deyo presents key arguments and information to those clinicians who treat patients complaining of back pain. He encourages the media – a big player in our medical-industrial complex — to be far more responsible and cautious about promoting the latest promise of cure. And he provides much needed help to back pain sufferers who, he argues, must arm themselves with good information to make good decisions. He also argues that the informed consent process needs to be revamped so that patients are informed not only about the risks of treatment but of “what is likely to happen if they don’t have the treatment or procedure.” Deyo points out that most discussions during the “informed consent process” are, in fact, exercises in “persuading a patient to agree with a recommendation rather than providing a balanced discussion of the options.”

Since Deyo’s book went to press, more damning information has come out about the perils of back surgery. It may it not work, and has the potential to do a great deal of harm. And, to add insult to injury, a New York Times article, which quoted Deyo, recently reported that patients may find that their surgeons engage in the scandalous practice of – without prior notification to the patient — calling in assistant surgeons who  present patients with a surprise bill for their services.

This book is truly essential reading for anyone who wants to make sure they get the right treatment for back pain and for those of us trying to figure out how to treat our very broken and all too painful healthcare system.

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