© American Academy of Pain Medicine 1526-2375/02/$15.00/349 349–351

ETHICS FORUM

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Edited by Michel Dubois

PAIN MEDICINE

Volume 3

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Number 4

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2002

A Lucrative Routine, Short on Pain Management

The Case

A 42-year-old white male patient has been experi-encing low back pain since a fall in 1993. He injuredhis back and right hip, he had no fractures at thetime, but his pain increased regularly over the fol-lowing 4 years. In 1997, he was attending a well-known pain clinic in the southern United States. Hisdiagnoses were: lumbar facet arthropathy, broad pos-terior herniation at L5-S1 without nerve root com-pression, and sacroiliac joint arthropathy. Duringthe following 3 years of treatment in this clinic, heunderwent a total of seven sacroiliac joint injectionsof steroids and local anesthetic, and six lower lumbarmedial branch nerve blocks with local anesthetics,followed by radiofrequency thermocoagulation. Themaximum duration of pain relief following any ofthose procedures was 2 months. Minimum informa-tion is provided to justify them. No clinical evalua-tion can be found in the patient’s chart in order tofollow the patient’s progress. No attempt was made toenroll the patient in a physiotherapy and/or a psy-chology program. No alternative pain intervention(except for analgesics) was used.

During his vacations, the patient got a secondmedical opinion for his back pain complaints. Thepain physician’s documented (clinically and fromnew MRI) findings were consistent with a lumbosac-ral radiculopathy due to a herniated L5-S1 disk.

How should this physician react? Tell the pa-tient that he received the wrong treatments allthese years? Contact the original pain clinic wherehe was followed in order to try to convince thetreating physician to change his/her medical man-agement? Since the patient is not, at this time,vindictive, but only in pain, say nothing about hispast care, give him a new (hopefully more adapted)treatment, and refer him back, with a letter, to hisoriginal physician? What else?

Opinion #1: Thalia Segal, MD

Good Ethical Decision is Akin to Good Medical Decision

If the case in question were merely an example of amissed diagnosis that perhaps presented atypically

or subtly in its early stages, misconduct would notbe an issue. Uncertainty is inherent to the nature ofhealth care. With the tincture of time, diagnosesbecome clarified, and the last opinion is closest to the“correct” diagnosis. It is the luxury of one giving asecond opinion not to stumble over the same pitfallsas one’s predecessor. Unfortunately, it appears thatthis is not a situation of an unusually complex situa-tion managed well, but of an ordinary situationmanaged poorly. It, furthermore, appears that the“Initial Pain Associates” (IPA) not only made thewrong diagnosis, but potentially harmed the patient.They subjected the patient to multiple procedures,lining their pockets, and providing no true relief.Such behavior is clearly in direct violation of AMAguidelines that state: A physician’s “first duty must beto the individual patient. This obligation must over-ride considerations of the reimbursement mechanismor specific financial incentives applied to a physiciansclinical practice.”[1]

The AMA also provides some guidance for properbehavior of second opinion providers. It is the respon-sibility of the “Secondary Pain Clinician” (SPC) to“provide the patient with a clear understanding ofthe opinion, whether or not it agrees with the rec-ommendations of the first physician.” Armed withthis information, the patient may draw his ownconclusion about the quality of care provided by theIPA. Acting autonomously, he may make his own de-cisions about punitive measures [2]. According to theAMA, however, the SPC’s overall professional obli-gation is not over. The AMA guidelines suggestthat the SPC should act as a whistle-blower and ex-pose their dissatisfaction with the IPA to relevantauthorities. The guidelines state: “A physician shallstrive to report physicians deficient in character orcompetence, or engaging in fraud or deception, toappropriate entities.”

Officially then, the SPC must, thus, be forthcomingto both the patient and to medical boards. But in prac-tice, such policing rarely, if ever, occurs. The SPCmay have selfish concerns, such as worry about reper-cussions from speaking out. “Whistle-blowers” havebeen sued for slander. Probably more concerningfor the SPC is the shame he/she may feel for “ex-posing” a colleague. Medicine is like a club or even

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an extended family. Deviations are best addressedfrom within, person to person, not to patients andnot to extrinsic governing bodies. Most likely theSPC will choose to turn the other cheek, do his/herbest to serve the patient, and, at the same time, al-low the IPA to save face. This is ethically accept-able, but probably not the ideal.

References

1 American Medical Association. Principles of medicalethics. Chicago, Ill.: American Medical Association;2002.

2 Haavi Morreim E. Am I my brother’s warden? Re-sponding to the unethical or incompetent colleague.Hastings Cent Rep 1993;23:19–27.

Thalia Segal, MD

NYU Medical CenterNew York, New York

Opinion #2: Vitaly Gordin, MD

Outcome Studies Help Ethics

This case presents several medical and ethical issues.After sustaining a fall, the patient developed lowback pain and hip pain, which became progressivelyworse in the course of the following 4 years. Basedon the procedures performed, I assume that the pa-tient’s pain was predominantly axial and injectionssuch as sacroiliac joint injections and medial branchnerve blocks of the lumbar facet joints are commonpractice for the treatment of these patients. Thereis no clear evidence from the literature that these pro-cedures provide patients with long-term benefits.However, in carefully selected patients who respondto diagnostic medial branch blocks, radiofrequencythermocoagulation can provide pain relief lastingfor up to 6 months. It is essential to document thepatient’s response to these procedures in order toassess the effectiveness and long-term benefits fromthese injections. As this patient developed a chronicpain syndrome, the treating physician should nothave relied on the spinal injections as the onlytreatment modality. A multidisciplinary approach,including physical therapy and psychological evalu-ation and treatment, should have been utilized. Thepatient should have been introduced to such treat-ment modalities as a regular exercise program, ifnecessary, a weight reduction program, relaxationtechniques, and imagery. In the majority of the pa-tients with chronic low back pain there are sleepand mood disturbances, which should be addressedaccordingly. On the other hand, the patient’s re-sponse to the sacroiliac joint injections with relief

lasting for 2 months is quite typical, and if they pro-vided the patient with pain relief, improved function,and improved quality of life, their performance wasjustified, as long as their number was limited in orderto decrease the side effects from corticosteroids.

During follow-up appointments, the patient shouldhave been asked about any new symptoms and,based on the findings on the physical examination,further diagnostic studies should have been or-dered. It appears that the patient developed newsymptoms consistent with lumbrosacral radiculopa-thy confirmed by new findings on the MRI. In myopinion, the physician who is seeing the patient fora second medical opinion should explain the newfindings to the patient and tell him that there are al-ternatives to the old treatments. They might includean epidural steroid trial. Based on the patient’s newsymptoms, he might also benefit from an evaluationby a spine surgeon. Having new symptoms consistentwith radiculopathy renders this patient as a potentiallyfavorable candidate for a spine surgery. I would tryto contact the original pain clinic and, in a noncon-frontational way, express my opinion and what Ifeel should be done for the patient. In addition tothat, I would send a letter with my findings and theproposed treatment plan to the original pain clinic.Once the patient has had his treatment options ex-plained to him, it is up to him whether he choosesto stay with the original pain clinic or try findinganother physician.

This case further emphasizes the importance ofoutcome studies for the treatment of chronic lowback pain. It also emphasizes the importance of amultidisciplinary approach to the treatment of thesepatients.

Vitaly Gordin, MD

Pennsylvania State UniversityHershey, Pennsylvania

Opinion #3: Diane Novy, PhD

Medical Interventions Should Benefit Patients

This case clearly demonstrates different approaches topain. During the patient’s 3-year treatment at the firstclinic, he had various and repetitive invasive proce-dures. Without a clear medical basis for these proce-dures or significant and durable pain relief, there is littlesupport for the repetition of these procedures. Instead,more extensive workup options and treatment optionsshould have been considered. A focus on long-termtreatment goals and consideration of the potentialcontributions of physical therapy and psychological in-tervention also were missing at this first clinic.

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From the second medical opinion, backed up witha new MRI, there is a diagnosis that would suggest therepetitive procedures performed in the first clinicwere not useful. However, the second physician doesnot know whether or not the patient’s symptoms havechanged.

In my opinion, the second physician should discussthe new diagnosis and treatment recommendationswith the patient. The patient should be given thechoice of following up with the second physician orreturning to the first physician. Regardless of thepatient’s decision, the second physician should getthe patient’s permission to communicate with the

first physician. The second physician should sendthe first physician a report of the new findings andthe new treatment plan. In the event that the pa-tient elects to be treated by the first physician, Iwould also suggest a phone conversation betweenthe two physicians in which the new findings andnew treatment plan are discussed. By so doing, thesecond physician makes sure the first physician re-ceives the new information.

Diane Novy, PhD

University of TexasHouston, Texas