Level Of "evidence" for Pain vs Other Medical Specialities

[DrCommonSense]

The discussion about "evidence" based medicine has been quite intriguing to me on these forums. I often see posters like "101N" who keep crying about the lack of "evidence" for certain types of procedures such as LESI due to the "need" for perfectly randomized placebo controlled studies including meta-analyses confirming efficacy before they are "proven", which can only be done by authors they deem appropriate (such as Chou). Basically, setting up a strawman level of evidence that doesn't exist anywhere else in medicine, as I will argue below.

The scrutiny the mILD procedure has received from CMS due to neurosurgical opposition really brought this home to me.

It seems like a level of scrutiny is applied to some of these procedures far in excess of the biggest cost drivers in medicine including procedures (cardiac, neurosurgery/ortho "back" surgeons, general ortho, etc) and pharmaceutical companies.

The mILD procedure is literally being forced to undergo many prospective randomized trials by CMS before approval. Compare this with many other procedures that have been much larger cost generators for Medicare that appear to increase every year , which have actual evidence proving they don't work for the vast majority of patients they are used on.

Kypho, RF, ESIs, etc will have more positive evidence for them than the procedures listed below that are FAR more expensive for CMS.

Examples below include:

100 billion dollar cardiac market (stents and CABGS)


A) Stents have basically NO evidence for any mortality benefit for >95% of cases where they are used for "stable CAD" rather than an acute MI.

One of many articles below confirming this fact:

http://circinterventions.ahajournals.org/content/5/4/476.long

The vast majority of studies prove there is NO evidence that stents work at all for stable CAD patients, especially compared to conservative medical therapy (Statins, ACE, etc)

B) CABG has no evidence for almost any patients outside of LMA disease with depressed EF compared to medical therapy

http://www.nejm.org/doi/full/10.1056/NEJM197709222971201

There are literally articles back from the 1970s until present showing the vast majority of CABG procedures offer no benefit compared to medication therapy, This is particularly true recently with newest medication therapies.

Only a handful of studies show some very SLIGHT mortality benefit for LMA disease with decreased EF

C) Most EP Ablation treatments have no evidence of mortality/morbidity benefit over conventional medication management in >99% of stable AF patients, yet cost 10s of thousands of dollars for each procedure.

Back Surgery World

A) Fusion surgery for Stenosis, DDD, Disc Herniation with radiculopathy: has literally no evidence to prove efficacy and plenty of evidence against it.

Hell, even most workman comp studies show that fusion causes increased disability and increase narcotic usage compared to CONSERVATIVE therapy such as PT, injections, medications, etc.

http://www.ncbi.nlm.nih.gov/pubmed/20736894

http://www.ncbi.nlm.nih.gov/pubmed/26709561

All independently done trials through workman compensation show increased disability and increased narcotic usage with decreased return to work status for fusion surgery used for ANY diagnosis.

B) Laminectomy surgery for Stenosis:

Only the SPORT trial shows any benefit for stenosis, which is SHORT term with a limited cohort of patients. The study was also performed by surgeons who have a financial interest in keeping the procedure going (compare this to the critique of "mILD")

Furthermore, the study only showed benefit in ONE level stenosis for a short period of time, with far less benefit for 2 or 3 levels of stenosis.

There are almost no other studies that show efficacy past 6 months for laminectomy.

Compared to CMS demands on the mILD procedure


Here are the makers of BMAC (who incidentally NOW HAVE MORE EVIDENCE for efficacy for treatment of DDD when compared to fusion surgery) showing yet another study confirming that Ortho spine surgeries just don't work:

http://www.regenexx.com/spinal-stenosis-surgery-questions/

Yet here CMS continues to pay 10s of billions more for this than conserative care.

Orthopedic World:

Biggest issue are arthroscopic surgeries for meniscus repair (100s of thousands/year) with MANY studies now confirming they have no benefit.

Rotator Cuff surgeries have surprising few studies confirming any benefit.

Pharma world:

Most recent cancer drugs that cost 10s of thousands have no evidence for any mortality benefit yet cost 10s of thousands per year.

http://www.cbsnews.com/news/cost-of-cancer-drugs-60-minutes-lesley-stahl-health-care/

Good expose that shows many CA drugs that have been approved by FDA over the last 15 years provide NO benefit in terms of mortality.

Lyrica is the biggest money making drug for Pfizer at the moment. It provides marginally better benefit than placebo and nothing really over Neurontin.

Lyrica costs 700/month with very little benefit proven in studies.

Antidepressant drugs such as Abilify are big sellers with marginal evidence only shown in industry supported trials.


I think this constant ridiculous standard we need for "evidence" that is applied by guys like 101N is getting tiresome and needs to be called out.

Let the games begin!

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[drusso]

The discussion about "evidence" based medicine has been quite intriguing to me on these forums. I often see posters like "101N" who keep crying about the lack of "evidence" for certain types of procedures such as LESI due to the "need" for perfectly randomized placebo controlled studies including meta-analyses confirming efficacy before they are "proven", which can only be done by authors they deem appropriate (such as Chou). Basically, setting up a strawman level of evidence that doesn't exist anywhere else in medicine, as I will argue below.

Yes! The Force is strong with this Padawan...let go...feel the power of critical thinking consume you...grab it..become it...

 

[DrCommonSense]

Yes! The Force is strong with this Padawan...let go...feel the power of critical thinking consume you...grab it..become it...

I can take the 101N's logic of evidence and apply it to almost any specialty. Let's have a look how that goes:

1) Cardiology: We shouldn't do stents, angioplasty, etc for anyone but people with an acute MI in the first three hours due to lack of mortality benefit. Even the "acute MI" patient benefits don't have "level 1 evidence" either (http://www.nejm.org/doi/full/10.1056/NEJMoa1208200), so they should be experimental.

We shouldn't use stress tests (40% false negative rates) or almost any other cardiology intervention.

Therefore, the only method that should be used is prescription for exercise, generic statins, ACE-Is, etc. as the only methods. Cardiology should move towards basically nutrition and generic medications with absolutely no procedures or stress tests due to lack of "level 1 evidence"

2) Orthopedic/Neurosurgical Spine: Fusions are OUT due to lack of evidence, laminectomy can only be used for healthy/younger patients with one level stenosis to outweigh cost vs benefit.

Therefore, spine surgeons should only do approximately 1 percent of their current surgical volume based on "level 1" evidence.

We probably can't prescribe any meds (no level 1 evidence), PT (no level 1 evidence), back brace (no level 1 evidence), etc.

So based on 101N logic, should just send these patients home to exercise and diet on their own.

3) General Orthopedics: No rotator cuff surgeries, no meniscus/other arthroscopic sugeries, no tendon/ligament surgeries due to lack of level 1 evidence.

TKR/THR can ONLY be performed on perfectly healthy/non obese/low risk patients (less than 3%) of the current level based on "level 1" evidence.

We should just stick with possible Rehab, diet, excercise.

Crap guys, basically almost every field of procedural medicine is gone by 101N logic. Lets do it!

4) Radiology:

Decrease MRIs to 2% of current volume at best for cervical/lumbar pathology due to lack of level 1 level evidence for their benefit in diagnosis stenosis/DDD or having a meaningful impact on treatment.

Basically, only about 2% of overall radiological studies in general are justified by level 1 evidence.

101N I suggest you propose that in the cardiology forums, back surgery forums, ortho forums, radiology forums, etc and make these proposals. Just propose good living, exercise, weight loss, sleep, etc and eliminate all of those fields of medicine!

That would be the only consistent position to take for 101N.

 

[101N]

So, your argument is to defend our waste because everybody else does it too?

 

[DrCommonSense]

Yes! The Force is strong with this Padawan...let go...feel the power of critical thinking consume you...grab it..become it...

Also, 101N appears to be a believer in "cognitive behavorial therapy" for "low back pain".

I have yet to see any LEVEL 1 placebo controlled double blinded studies confirming CBT works for a herniated disc, stenosis, DDD, etc.

101N please show me the studies that confirm CBT works better for these above diagnoses rather than placebo, since you keep arguing for this nonsense.

 

[DrCommonSense]

So, your argument is to defend our waste because everybody else does it too?

My argument is all of procedural medicine can't hold up to the level of scrutiny that you holding IPM procedures to.

By the logic of GREATEST benefit for society in terms of cost, since you pretend to "care" for patients so much, clearly you should be posting in the forums that cost the MOST amount of money for the society.

Considering cardiology, back surgeons, ortho surgeons, radiologists, etc. cost far more money with their lack of level 1 evidence for their procedures/diagnostic tests, you should be spending more effort in those forums trying to eliminate those fields.

Also, I recommend eliminating your field of psychiatry. You have no level 1 evidence for psychoanalysis, any anti depression drug/anti psychotic drugs, etc compared to psychologists.

I also recommend eliminating CBT entirely as well for treatment of back pain due to lack of level 1 evidence.

When are you going to do that champ? For some reason, I suspect your "crusade" will remain very selective.

 

[Stim4me]

I can take the 101N's logic of evidence and apply it to almost any specialty. Let's have a look how that goes:

1) Cardiology: We shouldn't do stents, angioplasty, etc for anyone but people with an acute MI in the first three hours due to lack of mortality benefit. Even the "acute MI" patient benefits don't have "level 1 evidence" either (http://www.nejm.org/doi/full/10.1056/NEJMoa1208200), so they should be experimental.

We shouldn't use stress tests (40% false negative rates) or almost any other cardiology intervention.

Therefore, the only method that should be used is prescription for exercise, generic statins, ACE-Is, etc. as the only methods. Cardiology should move towards basically nutrition and generic medications with absolutely no procedures or stress tests due to lack of "level 1 evidence"

2) Orthopedic/Neurosurgical Spine: Fusions are OUT due to lack of evidence, laminectomy can only be used for healthy/younger patients with one level stenosis to outweigh cost vs benefit.

Therefore, spine surgeons should only do approximately 1 percent of their current surgical volume based on "level 1" evidence.

We probably can't prescribe any meds (no level 1 evidence), PT (no level 1 evidence), back brace (no level 1 evidence), etc.

So based on 101N logic, should just send these patients home to exercise and diet on their own.

3) General Orthopedics: No rotator cuff surgeries, no meniscus/other arthroscopic sugeries, no tendon/ligament surgeries due to lack of level 1 evidence.

TKR/THR can ONLY be performed on perfectly healthy/non obese/low risk patients (less than 3%) of the current level based on "level 1" evidence.

We should just stick with possible Rehab, diet, excercise.

Crap guys, basically almost every field of procedural medicine is gone by 101N logic. Lets do it!

4) Radiology:

Decrease MRIs to 2% of current volume at best for cervical/lumbar pathology due to lack of level 1 level evidence for their benefit in diagnosis stenosis/DDD or having a meaningful impact on treatment.

Basically, only about 2% of overall radiological studies in general are justified by level 1 evidence.

101N I suggest you propose that in the cardiology forums, back surgery forums, ortho forums, radiology forums, etc and make these proposals. Just propose good living, exercise, weight loss, sleep, etc and eliminate all of those fields of medicine!

That would be the only consistent position to take for 101N.

CMS would like us to prescribe hugs and kisses.... I like this guy/gal...
Don't forget, if you're a top utilizer of these treatments the "deep state" puts a target on your practice...

 

[DrCommonSense]

CMS would like us to prescribe hugs and kisses.... I like this guy/gal...
Don't forget, if you're a top utilizer of these treatments the "deep state" puts a target on your practice...

BMAC studies compiled with basic science literature concerning treatment of DDD of the spine: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737050/

Fusion Meta Analysis where the conclusions state "don't need RCT to study fusions" because well the studies conclusively show they work poorly for DDD.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4472285/


BMAC actually has more evidence for treatment of DDD than Fusion surgery at this time in terms of "evidence".

When is 101N going to crusade against fusion surgery due to lack of evidence? When is he going to support CMS paying for BMAC while eliminating fusion?

When is 101N going to crusade to get mILD paid for by CMS due to being cheaper/more cost effective with similar efficacy as laminectomy for older patients with stenosis due to hypertrophy of ligamentum flavum (70-80% of cases) confirmed by two recent RCT studies that just came out this year?



Im still also waiting on 101N showing me ANY studies with RCTs confirming CBT benefits for DDD, herniated discs, etc vs placebo.

 

[Ligament]

My argument is all of procedural medicine can't hold up to the level of scrutiny that you holding IPM procedures to.

By the logic of GREATEST benefit for society in terms of cost, since you pretend to "care" for patients so much, clearly you should be posting in the forums that cost the MOST amount of money for the society.

Considering cardiology, back surgeons, ortho surgeons, radiologists, etc. cost far more money with their lack of level 1 evidence for their procedures/diagnostic tests, you should be spending more effort in those forums trying to eliminate those fields.

Also, I recommend eliminating your field of psychiatry. You have no level 1 evidence for psychoanalysis, any anti depression drug/anti psychotic drugs, etc compared to psychologists.

I also recommend eliminating CBT entirely as well for treatment of back pain due to lack of level 1 evidence.

When are you going to do that champ? For some reason, I suspect your "crusade" will remain very selective.

We are happy to have a new member with good arguments to the forum, but lets keep personal attacks against 101N toned down. We (mostly) all know each other here in real life, no need to piss anybody off.

 

[DrCommonSense]

We are happy to have a new member with good arguments to the forum, but lets keep personal attacks against 101N toned down. We (mostly) all know each other here in real life, no need to piss anybody off.

I am not attacking his person, I just find him suspect from some kind of "honest broker" standpoint. He seems to emphasize "evidence" selectively when it comes to IPM but basically for no other field to the same degree.

For instance, look at his stance on CBT. He has literally ZERO evidence in terms of RCT or even observational studies that confirm this modality has any benefit for stenosis/DDD/disc herniations/spondylosis, yet makes comments like CBT>>>RF in other posts.

I've been lurking on this forum and find him consistently fully negative towards IPM exclusively to the degree that I don't even know why he even practices the field.

What is his PRIMARY specialty? I would love to critique his background like his does to IPM. I suspect it's psychiatry, which would be EXTREMELY easy to defeat from an evidence based background.

I suspect his primary specialty stands in a glass house that can be easily critiqued far worse than IPM.

 

[101N]

My back ground is PM&R, what's yours and what professional societies - guilds - do you belong to?
ASIPP?

 

[DrCommonSense]

My back ground is PM&R, what's yours and what professional societies - guilds - do you belong to?
ASIPP?

What RCTs show that physical therapy improves VAS or Disability Scores over the long haul for stenosis? Lets compare that to say the mILD procedure. Why should CMS pay for Rehab over mILD considering mILD has more evidence in terms of pubmed articles and RCTs .

Also, show me the RCTs that show CBT improve VAS/OWDI for spinal stenosis due to liagmentum hypertrophy compared to mILD procedure.

Yes, I am part of ASIPP, ASA and AAPM. I come from an anesthesiology background as well.

 

[Stim4me]

I am not attacking his person, I just find him suspect from some kind of "honest broker" standpoint. He seems to emphasize "evidence" selectively when it comes to IPM but basically for no other field to the same degree.

For instance, look at his stance on CBT. He has literally ZERO evidence in terms of RCT or even observational studies that confirm this modality has any benefit for stenosis/DDD/disc herniations/spondylosis, yet makes comments like CBT>>>RF in other posts.

I've been lurking on this forum and find him consistently fully negative towards IPM exclusively to the degree that I don't even know why he even practices the field.

What is his PRIMARY specialty? I would love to critique his background like his does to IPM. I suspect it's psychiatry, which would be EXTREMELY easy to defeat from an evidence based background.

I suspect his primary specialty stands in a glass house that can be easily critiqued far worse than IPM.

The forum members don't like to hear the truth... You keep it up baby... I don't read any disrespect in your comments pure fact based opinion. You don't have to reveal your identity either, the members cried about this in the past so remain as anonymous as you like... Proceed .

Please educate me on why PT and conservative care for 2-6 weeks is always mandatory prior to a spinal intervention. Is this biased clinical evidence manipulated by the NIH and CMS a-holes that control medicine (i.e. 15 person ACA advisory board)?

 

[101N]

I am glad you are here. Welcome to the forum

 

[BobBarker]

I like what you are bringing to the table but 101 is right about some things. just like anything, the truth is somewhere in the middle.

 

[Stim4me]

The truth is that we don't have the money or time to definitively prove interventional and medication options. It took 20+ years for the fda to approve gabapentin for neuropathic pain... That's nuts. Most studies can barely cover the cost to follow patients for 2-3 years post intervention or surgery...

We need more free market sectors in medicine, more infusion of capital and financial incentives prove our therapies. It ain't gonna happen with the current plight of healthcare... Need a medical boom akin to a tech boom.

 

[DrCommonSense]

I am glad you are here. Welcome to the forum

Thanks for the welcome but I notice you avoided my comment.

From a "level 1" based evidence standpoint, your whole field of Rehabilitation medicine, particularly for outpatient conditions such as spinal stenosis/DDD/disc herniations shouldn't exist.

What do you do when running a patient on a treadmill or doing "core exercises" fail to alleviate pain and improve function. We are referred literally 1000s of patients per year from Rehab/Ortho groups AFTER having 5-8 weeks of PT due to remaining pain.

If we go by your logic of "level 1 evidence", we really can't offer them anything. Forget fusions, laminectomy, etc.

I ask the question again, where is your LEVEL 1 RCT trials that show PT benefits people with stenosis? Why do we have CMS spending 1000s of dollars a year on "months" of PT service annually without evidence?

Why are we spending thousands of dollars on PT when the mILD procedure has actual RCT trials now with 100s of patients that show improvement of VAS and Owestry Disability Index Scores at the 1 year mark and longer?

Also, why do we use CBT for these conditions without RCT trials?

(At the place that I work, we have our own PT and Behavorial Therapies offering these options and are often implemented)

 

[101N]

Since MILD seems to be a particular interest of yours, why don't we start a discussion of
it in another thread? You present your evidence and opinions, bring you friends, and I
will do the same

 

[DrCommonSense]

I like what you are bringing to the table but 101 is right about some things. just like anything, the truth is somewhere in the middle.

I am actually in the middle. I never said LESI/RF of MBBs/Kypho/mILD/SCS/etc are the "be all end all" that will cure everything.

However, 101N basically says there is no evidence for opioids and interventions based upon "level 1" evidence, so we should get rid of it all.

Yet he fails to mention what will replace this? Fusions? Laminectomy? More PT? NSAIDs?

 

[DrCommonSense]

Since MILD seems to be a particular interest of yours, why don't we start a discussion of
it in another thread? You present your evidence and opinions, bring you friends, and I
will do the same

mILD isn't the only argument of mine, it is just one part.

You have yet to prove that your whole field of Rehabilitation has ANY level 1 evidence for DDD/Stenosis/Disc Herniations/etc. Or basically anything else.

Why don't we just hire some random PT guy and have him show a patient a few exercises during 1 session and get rid of the whole field of PMR? That would be more cost effective and have as much "level 1 evidence" as anything you present.

Please show me these "studies" confirming this. Its easy to throw stones in glass houses.

A guy coming from a field with literally NO RCT studies confirming anything it does giving a critical analysis about another field of medicine.

 

[DrCommonSense]

The truth is that we don't have the money or time to definitively prove interventional and medication options. It took 20+ years for the fda to approve gabapentin for neuropathic pain... That's nuts. Most studies can barely cover the cost to follow patients for 2-3 years post intervention or surgery...

We need more free market sectors in medicine, more infusion of capital and financial incentives prove our therapies. It ain't gonna happen with the current plight of healthcare... Need a medical boom akin to a tech boom.

Our group does very well under "free market" conditions in our area. Considering the high deductible plans, patients have to basically pay for the first 6K of their own care.

These patients can choose the local Rehab hospital, surgeons, PCPs, etc. They choose to come see us because they like their results. No one is putting a gun to their heads.

 

[Ducttape]

i think, unfortunately, you are the one using the strawman argument.


er, um... 101N is not a cardiologist or cardiothoracic surgeon, an orthopedic surgeon, or pharmacist. his specialty is pain medicine.

i would not expect him to take a major interest in non-pain procedures, when there is much debate about pain procedures itself.

 

[Ducttape]

fyi, you did post a lot of information, and obviously had a lot of prep time. just to make a quick note...

on your first post, insurance are not recommending or "allowing" cardiac cath for stable angina. these are evicore guidelines.

Diagnostic Left Heart Catheterization - Indications
1.
Identifying disease for which invasive procedures have been shown to prolong survival:
o
Left main coronary artery disease plus right coronary artery disease plus left ventricular dysfunction.
o
Triple vessel coronary artery disease plus left ventricular dysfunction.
2.
Unstable (new, accelerating, or worsening) angina, even in the absence of noninvasive cardiac testing.
3.
Symptomatic patients with a high pretest probability of CAD.
4.
Angina that is unresponsive to optimized medicaltherapy (see CD-1) and for which invasive procedures are needed to provide pain relief.
5.
Left ventricular dysfunction (congestive heart failure) in patients suspected of having coronary artery disease
6.
Ventricular fibrillation or ventricular tachycardia where the etiology is unclear
7.
Unheralded syncope (not near syncope)
8.
Recent noninvasive cardiac testing was equivocal, unsuccessful in delineating the clinical problem, or led to a conclusion that intervention is indicated for the following conditions
:
o
Suspicion of cardiomyopathy, endocarditis, or myocarditis
o
Significant/serious ventricular arrhythmia
o
Evaluating progression of known CAD when symptoms are persistent or worsening
o
An intermediate or large amount of myocardium (>5%) may be in jeopardy
o
Evaluation of coronary grafts
o
Evaluation of previously placed coronary artery stents
o
Evaluation of structural disease
9.
Ruling out coronary artery disease prior to planned non-coronary cardiac or great vessel surgery (cardiac valve surgery, aortic dissection, aortic aneurysm, congenital disease repair such as atrial septal defect, etc.)
10.
Assessment for accelerated coronary artery disease associated with cardiac transplantation
11.
Pre-organ transplant (non-cardiac). Some institutions perform a heart cath as part of their initial evaluation protocol. Others use an imaging stress test for evaluation.
Either is appropriate and can be approved but NOT both.
12.
Valvular heart disease when there is a discrepancy between the clinical findings
(history, physical exam, and non-invasive test results) or valvular surgery is being considered.
13.
Suspected pericardial disease.

 

[DrCommonSense]

i think, unfortunately, you are the one using the strawman argument.


er, um... 101N is not a cardiologist or cardiothoracic surgeon, an orthopedic surgeon, or pharmacist. his specialty is pain medicine.

i would not expect him to take a major interest in non-pain procedures, when there is much debate about pain procedures itself.

Ok, clearly his fund of knowledge is far more limited than myself on these various fields of medicine and "level one" guidelines. The purpose was to show that using "level 1" evidence for basically any procedural field of medicine could produce the same conclusions that 101N makes about pain medicine. This is not a "strawman" to show that basically all of procedural medicine fails this test.

101N does come from a PMR background. Surely, he can discuss the fact that PT has NEVER been studied using "level 1" evidence proving efficacy for stenosis/DDD/failed back syndrome/spondylosis/etc. Why doesn't he spend more time complaining about the 1000s of wasted dollars spent on medicare patients concerning Rehab physician utilization and PT considering they have no level one EBM supporting them? He had more time in residency doing PMR than his Pain Fellowship.

Why just pick on pain medicine only with such very high standards that can't be replicated in ANY other field of medicine? Also, why practice pain at all if you don't believe in any of the procedures? Surely he can practice PMR exclusively despite its lack of level 1 evidence if it makes him feel better.

Or better yet 101N should open up a yoga studio and quit medicine considering his primary field of medical study offers zero level one evidence for anything it does. That would only be fair to the patients. Why waste medical dollars that is already strained?

 

[DrCommonSense]

fyi, you did post a lot of information, and obviously had a lot of prep time. just to make a quick note...

on your first post, insurance are not recommending or "allowing" cardiac cath for stable angina. these are evicore guidelines.

You just posted diagnostic cath guidelines. I spoke about cardiac stents for stable CAD. Don't see how this is relevant.

 

[hyperalgesia]

I think this constant ridiculous standard we need for "evidence" that is applied by guys like 101N is getting tiresome and needs to be called out.
Let the games begin!

It's not ridiculous at all. As you pointed out in another one of your posts, I paraphrase, "95% of medical issues can be resolved with wt loss, exercise and diet..." 101N is keeping us grounded and applying a higher standard than your examples. We can certainly get away with setting an insultingly low bar as used by shysters in other medical specialties as you aptly noted. And we certainly have a great incentive for doing so.

 

[DrCommonSense]

It's not ridiculous at all. As you pointed out in another one of your posts, I paraphrase, "95% of medical issues can be resolved with wt loss, exercise and diet..." 101N is keeping us grounded and applying a higher standard than your examples. We can certainly get away with setting an insultingly low bar as used by shysters in other medical specialties as you aptly noted. And we certainly have a great incentive for doing so.

I don't disagree with this premise if its applied across the board STARTING with the HIGHEST cost drivers. Once we demand "level 1" evidence across the board for all of procedural medicine, we probably wouldn't have any procedural medicine left.

We would literally have to eliminate stents for stable CAD/possibly unstable CAD, Fusions, Laminectomy in >97% of cases, Arthroscopic Surgery, Rotator Cuff Surgery, Knee Replacement for >95% of population, THR for >95% of population, etc.

But most patients want procedures or a pill for a "quick fix", pharma has huge market caps and lobbying power, device companies have the same issues, etc. Very complicated issue.

Don't get me started on pharma either. We would have to eliminate basically 95%+ of patented pharma drugs based on cost/benefit parameters alone using "level 1" evidence.

 

[Ducttape]

- you take words out of context. i never said he was limited. he chooses not to discuss topics that are not his specialty, which is a tactic that i would highly recommend to anyone.

there is enough work as evidenced by this thread to focus on what he has chosen to specialize on. im also fairly certain his opinion will be rapidly disregarded if he were to post on the cardiology forums, for example.

- i know i do not recommend PT as the sole treatment modality. very rarely will there be level 1 evidence for anything in medicine. the issue that he has is that IPM unfortunately has become the de rigueur for pain treatment, when a significant portion of the population will not respond or will do worse with interventional procedures.

i daresay the average pain patient that a private practice pain doc sees is middle aged, working, making $50k, has spouse and kids, and is very invested in getting better and back to work. they get better with IPM, because they are motivated, and are not catastrophizing, not seeking opioids or disability or marijuana. those latter patients are not appropriate for IPM, but presently the majority of their pain treatment is in the form of IPM +/- opioids +/- SSD...


- to your final point, yes, i did post diagnostic cath criteria, primarily because i thought it unlikely someone would get PCI without an initial cath, and also because i didnt want to read this entire document:
http://content.onlinejacc.org/article.aspx?articleid=1147816

which leads me to one last salient point. Pain Medicine has historically been involved in too much influence peddling, whether it is with Big Pharma and opioids or IPM. at least in cardiology, there is an organization that posts standards that appear to be not influenced by monetary gain. can one say the same about the varied guidelines from the 3-4 different pain societies regarding recommendations towards procedures? we as a field do not have any consensus about appropriate treatment.

too many hands in the pot.

 

[DrCommonSense]

- you take words out of context. i never said he was limited. he chooses not to discuss topics that are not his specialty, which is a tactic that i would highly recommend to anyone.

there is enough work as evidenced by this thread to focus on what he has chosen to specialize on. im also fairly certain his opinion will be rapidly disregarded if he were to post on the cardiology forums, for example.

- i know i do not recommend PT as the sole treatment modality. very rarely will there be level 1 evidence for anything in medicine. the issue that he has is that IPM unfortunately has become the de rigueur for pain treatment, when a significant portion of the population will not respond or will do worse with interventional procedures.

i daresay the average pain patient that a private practice pain doc sees is middle aged, working, making $50k, has spouse and kids, and is very invested in getting better and back to work. they get better with IPM, because they are motivated, and are not catastrophizing, not seeking opioids or disability or marijuana. those latter patients are not appropriate for IPM, but presently the majority of their pain treatment is in the form of IPM +/- opioids +/- SSD...


- to your final point, yes, i did post diagnostic cath criteria, primarily because i thought it unlikely someone would get PCI without an initial cath, and also because i didnt want to read this entire document:
http://content.onlinejacc.org/article.aspx?articleid=1147816

which leads me to one last salient point. Pain Medicine has historically been involved in too much influence peddling, whether it is with Big Pharma and opioids or IPM. at least in cardiology, there is an organization that posts standards that appear to be not influenced by monetary gain. can one say the same about the varied guidelines from the 3-4 different pain societies regarding recommendations towards procedures? we as a field do not have any consensus about appropriate treatment.

too many hands in the pot.

Your argument is all across the board here, so I will attempt to answer it piecemeal.

The argument that only people who practice a specific field of medicine can comment on it is ridiculous by 101N standards considering he often quotes a guy named Chou who is a primary doc. So by that logic, no one can evaluate IPM procedures unless they are fellowship trained in pain.

1) You don't recommend PT as a sole modality? So how does this negate the fact that there are NO RCT proving that it works? Thanks for admitting there is almost never level 1 evidence for anything in procedural medicine.

2) I agree on your IPM assessment and that is true for our practice

3) Cardiology has plenty of "influence peddling" based upon the cath companies that make 10s of thousands for each stent. Who do you think pushed to increase stenting to such ridiculously high levels? You think that 50 billion industry that has ZERO level one evidence for benefit came out of nowhere?

Where did the ACC get its "guidelines" from? It has NO LEVEL ONE evidence to support stenting so many people. Do you honestly think "consultant" cardiologists who work for device companies aren't "peddling influence"? Or their lobbies that push for these treatments?

Whose pushing for EP treatment for A-fib when it has no benefit over medical management? Please don't pretend there isn't MASSIVE influence peddling involved here.

Big Pharma has pushed psychiatric drugs with no evidence, benzos with no evidence, celebrex, lyrica, etc. I would blame that on big Pharm more than anyone. Show me where Pain Medicine is unique in this regard? ALL FIELDS of medicine have "consultant" physicians pushing big pharma drugs that show little if any benefit, especially when compared to generics.

Everyone in medicine is guilty of "peddling" influence.

 

[NJPAIN]

Since MILD seems to be a particular interest of yours, why don't we start a discussion of
it in another thread? You present your evidence and opinions, bring you friends, and I
will do the same

SDNs version of West Side Story


Sent from my iPhone using SDN mobile app

 

[lonelobo]

SDNs version of West Side Story


Sent from my iPhone using SDN mobile app

Ya but who are the Sharks?

 

[VA Hopeful Dr]

I don't disagree with this premise if its applied across the board STARTING with the HIGHEST cost drivers. Once we demand "level 1" evidence across the board for all of procedural medicine, we probably wouldn't have any procedural medicine left.

We would literally have to eliminate stents for stable CAD/possibly unstable CAD, Fusions, Laminectomy in >97% of cases, Arthroscopic Surgery, Rotator Cuff Surgery, Knee Replacement for >95% of population, THR for >95% of population, etc.

But most patients want procedures or a pill for a "quick fix", pharma has huge market caps and lobbying power, device companies have the same issues, etc. Very complicated issue.

Don't get me started on pharma either. We would have to eliminate basically 95%+ of patented pharma drugs based on cost/benefit parameters alone using "level 1" evidence.

Actually, I'd be OK with eliminating most of what you're suggesting. Heck, as a pain doctor I'd expect you to be against most Fusions anyway as they tend to fail and leave you stuck with a patient in significant pain.

Most of the ortho surgeries that have poor evidence are for degenerative issues. Surgery for acute rotator cuff tears has decent evidence, same for meniscus repair.

 

[SSdoc33]

DrCommonSense, ease up on PM&R. if you really dont know about the field, you shouldnt blast it. it is like you are looking for a fight -- but im not sure why.

the vast majority of us, 101n included, do very little of our primary specialty.

you become a C5 quad, you are gonna want a physiatrist around.

 

[pmrmd]

^or someone willing to pull the trigger...

 

[NJPAIN]

Ya but who are the Sharks?

That's clear. More important question, who is Maria?

 

[DrCommonSense]

Actually, I'd be OK with eliminating most of what you're suggesting. Heck, as a pain doctor I'd expect you to be against most Fusions anyway as they tend to fail and leave you stuck with a patient in significant pain.

Most of the ortho surgeries that have poor evidence are for degenerative issues. Surgery for acute rotator cuff tears has decent evidence, same for meniscus repair.

Where is this "decent" evidence for meniscus tear surgeries? Surely, there is no level 1 evidence.

http://www.medscape.com/viewarticle/866424

 

[DrCommonSense]

DrCommonSense, ease up on PM&R. if you really dont know about the field, you shouldnt blast it. it is like you are looking for a fight -- but im not sure why.

the vast majority of us, 101n included, do very little of our primary specialty.

you become a C5 quad, you are gonna want a physiatrist around.

I am just taking the natural conclusions of 101N's crusade to bring "evidence based medicine" which only includes level 1 evidence as the sole criteria for benefit.

Using this approach on his primary specialty, I can conclusively show that Rehab should be fully eliminated for all outpatient pathology due to lack of evidence. I am unsure about inpatient Rehab evidence as that doesn't interest me much but I can conclusively state there is absolutely no level 1 evidence for anything Rehab does on an outpatient basis.

Why do you consider it "looking for a fight" when I treat PMR like 101N treats pain medicine? By that logic, 101N has been "picking a fight" for years demanding level 1 evidence for pain procedures.

 

[Stim4me]

Don't forget about the massive oncology costs to society, and voodo infusions based on shame studies as well. Cost in billions: onc>card>msk. Nobody ever tells a dying patients their cocktail is likely to provide minimal long term survival... Proceed.

I agree PT and PMR-directed PT is purely a tool to deny interventional and more comprehensive care...common sense remember you are out numbered 5-1 by physiatrist on this forum...they don't like their turf questioned .

 

[DrCommonSense]

Don't forget about the massive oncology costs to society, and voodo infusions based on shame studies as well. Cost in billions: onc>card>msk. Nobody ever tells a dying patients their cocktail is likely to provide minimal long term survival... Proceed.

I agree PT and PMR-directed PT is purely a tool to deny interventional care...

I notice that PMR physicians consider it "picking a fight" to apply level 1 evidence to their field. Why is this considered "picking a fight" when I do this to their field but not when they attempt this reasoning towards IPM?

Interesting how that works huh?

 

[DrCommonSense]

Actually, I'd be OK with eliminating most of what you're suggesting. Heck, as a pain doctor I'd expect you to be against most Fusions anyway as they tend to fail and leave you stuck with a patient in significant pain.

Most of the ortho surgeries that have poor evidence are for degenerative issues. Surgery for acute rotator cuff tears has decent evidence, same for meniscus repair.

Dunno what you mean by "acute" rotator cuff surgery either but all level 1 evidence points to rotator cuff surgeries offering no benefit over physiotherapy alone.

http://www.jwatch.org/na39597/2015/11/17/surgery-ineffective-atraumatic-rotator-cuff-tears

 

[Stim4me]

I notice that PMR physicians consider it "picking a fight" to apply level 1 evidence to their field. Why is this considered "picking a fight" when I do this to their field but not when they attempt this reasoning towards IPM?

Interesting how that works huh?

Dude your preaching to the choir. Even the moderators are schewed in supporting their buddy physiatrists on this forum... I've had my issues as well. Truth hurts sometimes. Keep it up though, we need fresh blood in this stale forum...plus your comments are spot on by the way

 

[VA Hopeful Dr]

Where is this "decent" evidence for meniscus tear surgeries? Surely, there is no level 1 evidence.

http://www.medscape.com/viewarticle/866424

That article is for degenerative tears (which is what I pointed out). Even your study doesn't address traumatic tears.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4095015/

"Meniscal repair shows 80% success at 2 years and is more suitable in younger patients with reducible tears that are peripheral (e.g., nearer the capsular attachment) and horizontal or longitudinal in nature." This doesn't specifically talk about traumatic tears, but that's how young people damage them.

 

[VA Hopeful Dr]

Dunno what you mean by "acute" rotator cuff surgery either but all level 1 evidence points to rotator cuff surgeries offering no benefit over physiotherapy alone.

http://www.jwatch.org/na39597/2015/11/17/surgery-ineffective-atraumatic-rotator-cuff-tears

Acute = traumatic, and that article is specifically about atraumatic tears.

http://www.ncbi.nlm.nih.gov/pubmed/26209913

Why look, good evidence that traumatic rotator cuff tears do very well with surgery. I wasn't able to find anything comparing operative to nonoperative in traumatic tears, but I bet we see something about that in the next year or so given how things are playing out currently.

 

[Timeoutofmind]

The discussion about "evidence" based medicine has been quite intriguing to me on these forums. I often see posters like "101N" who keep crying about the lack of "evidence" for certain types of procedures such as LESI due to the "need" for perfectly randomized placebo controlled studies including meta-analyses confirming efficacy before they are "proven", which can only be done by authors they deem appropriate (such as Chou). Basically, setting up a strawman level of evidence that doesn't exist anywhere else in medicine, as I will argue below.

The scrutiny the mILD procedure has received from CMS due to neurosurgical opposition really brought this home to me.

It seems like a level of scrutiny is applied to some of these procedures far in excess of the biggest cost drivers in medicine including procedures (cardiac, neurosurgery/ortho "back" surgeons, general ortho, etc) and pharmaceutical companies.

The mILD procedure is literally being forced to undergo many prospective randomized trials by CMS before approval. Compare this with many other procedures that have been much larger cost generators for Medicare that appear to increase every year , which have actual evidence proving they don't work for the vast majority of patients they are used on.

Kypho, RF, ESIs, etc will have more positive evidence for them than the procedures listed below that are FAR more expensive for CMS.

Examples below include:

100 billion dollar cardiac market (stents and CABGS)


A) Stents have basically NO evidence for any mortality benefit for >95% of cases where they are used for "stable CAD" rather than an acute MI.

One of many articles below confirming this fact:

http://circinterventions.ahajournals.org/content/5/4/476.long

The vast majority of studies prove there is NO evidence that stents work at all for stable CAD patients, especially compared to conservative medical therapy (Statins, ACE, etc)

B) CABG has no evidence for almost any patients outside of LMA disease with depressed EF compared to medical therapy

http://www.nejm.org/doi/full/10.1056/NEJM197709222971201

There are literally articles back from the 1970s until present showing the vast majority of CABG procedures offer no benefit compared to medication therapy, This is particularly true recently with newest medication therapies.

Only a handful of studies show some very SLIGHT mortality benefit for LMA disease with decreased EF

C) Most EP Ablation treatments have no evidence of mortality/morbidity benefit over conventional medication management in >99% of stable AF patients, yet cost 10s of thousands of dollars for each procedure.

Back Surgery World

A) Fusion surgery for Stenosis, DDD, Disc Herniation with radiculopathy: has literally no evidence to prove efficacy and plenty of evidence against it.

Hell, even most workman comp studies show that fusion causes increased disability and increase narcotic usage compared to CONSERVATIVE therapy such as PT, injections, medications, etc.

http://www.ncbi.nlm.nih.gov/pubmed/20736894

http://www.ncbi.nlm.nih.gov/pubmed/26709561

All independently done trials through workman compensation show increased disability and increased narcotic usage with decreased return to work status for fusion surgery used for ANY diagnosis.

B) Laminectomy surgery for Stenosis:

Only the SPORT trial shows any benefit for stenosis, which is SHORT term with a limited cohort of patients. The study was also performed by surgeons who have a financial interest in keeping the procedure going (compare this to the critique of "mILD")

Furthermore, the study only showed benefit in ONE level stenosis for a short period of time, with far less benefit for 2 or 3 levels of stenosis.

There are almost no other studies that show efficacy past 6 months for laminectomy.

Compared to CMS demands on the mILD procedure


Here are the makers of BMAC (who incidentally NOW HAVE MORE EVIDENCE for efficacy for treatment of DDD when compared to fusion surgery) showing yet another study confirming that Ortho spine surgeries just don't work:

http://www.regenexx.com/spinal-stenosis-surgery-questions/

Yet here CMS continues to pay 10s of billions more for this than conserative care.

Orthopedic World:

Biggest issue are arthroscopic surgeries for meniscus repair (100s of thousands/year) with MANY studies now confirming they have no benefit.

Rotator Cuff surgeries have surprising few studies confirming any benefit.

Pharma world:

Most recent cancer drugs that cost 10s of thousands have no evidence for any mortality benefit yet cost 10s of thousands per year.

http://www.cbsnews.com/news/cost-of-cancer-drugs-60-minutes-lesley-stahl-health-care/

Good expose that shows many CA drugs that have been approved by FDA over the last 15 years provide NO benefit in terms of mortality.

Lyrica is the biggest money making drug for Pfizer at the moment. It provides marginally better benefit than placebo and nothing really over Neurontin.

Lyrica costs 700/month with very little benefit proven in studies.

Antidepressant drugs such as Abilify are big sellers with marginal evidence only shown in industry supported trials.


I think this constant ridiculous standard we need for "evidence" that is applied by guys like 101N is getting tiresome and needs to be called out.

Let the games begin!

Nice post!

I do think you are fundamentally misrepresenting the issue at hand here.

The crux of the issue with EBM and IPM, is not that their is "insufficient evidence that IPM works" e.g. I don't know, the studies have not been done, maybe if we do some more studies we can prove the stuff works.

The actual issue is that there are a variety of negative studies published for many of the procedures (and their accompanying indications) we commonly perform. Therefore, we are not in a position to claim "absence of evidence does not imply evidence of absence" with respect to the evidence.

Hence, the strategy is to critique these negative studies. "Wrong patient selection, inappropriate technical approach, hidden confounders, etc.". This seems to be the logical approach, because, after all, there are a lot of positive studies for these procedures too!!!!

Which is to say, either you have to explain the negative studies away as I have indicated, or bail on IPM all together and take the position that the positive studies that have been published are biased/false and explain those away. After all, the negative and the positive studies both cannot be right!

So the devil really is in the details. And many of the studies are a very poor quality. And pain/pain patients are so complicated it is really tough.

In either case " The absence of level one evidence" does not seem to me to be the issue with our field.

I think the better case to be for IPM is quite simple: it kinda sucks but it beats the alternatives in terms of efficacy and especially in terms of side effects for the non-crazies. How many people are wrecked by opioids, NSAIDs, spine surgery, every year?...astronomical numbers!!!!! How about by ESIs/SCS/RFAs...extremely rare. (For the crazies, 101ns do nothing/psychotherapy approach is obviously the correct route. But I think it is pretty disingenuous to deny that there is a significant non crazy subset of the population with chronic pain.)

If I was in horrible chronic pain, I would rather have the best alternative even if it was very poor. So personally, I can honestly say, I would have an ESI if I had a raging radiculopathy... despite the fact that the published literature on ESIs is all over the place (which to me implies that it is probably a procedure with modest efficacy, if used in appropriately selected patients... If ESIs had excellent efficacy, I do feel that the state of the literature would be less ambiguous ).

But the actual reality of our situation, is that this is all infinitely complicated by the two facts that 1. Pain is a subjective, personal mental state which is impossible to objectively measure 2. IPM pays well. And those two facts can only result in one possible outcome given human nature: many IPM physicians are basically horrible people and unscrupulous and often fraudulent. Hence the increasing scrutiny in the field, which is really not deserved compared to other fields, based on the current state of the evidence. Which is what I think your original point was getting at.

This is all commonsense, but tough to keep it all in mind when you are staring a negative study in the face!

I know this is a long post, but I found these issues so confusing and discouraging prior to starting fellowship and during fellowship. Hopefully some of these thoughts are helpful to potential future IPM docs.

 

[drusso]

But the actual reality of our situation, is that this is all infinitely complicated by the two facts that 1. Pain is a subjective, personal mental state which is impossible to objectively measure 2. IPM pays well. And those two facts can only result in one possible outcome given human nature: many IPM physicians are basically horrible people and unscrupulous and often fraudulent. Hence the increasing scrutiny in the field, which is really not deserved compared to other fields, based on the current state of the evidence. Which is what I think your original point was getting at.

Uh? Some of the most inspiring and intelligent people I've met in life are IPM physicians.

 

[DrCommonSense]

That article is for degenerative tears (which is what I pointed out). Even your study doesn't address traumatic tears.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4095015/

"Meniscal repair shows 80% success at 2 years and is more suitable in younger patients with reducible tears that are peripheral (e.g., nearer the capsular attachment) and horizontal or longitudinal in nature." This doesn't specifically talk about traumatic tears, but that's how young people damage them.

Acute = traumatic, and that article is specifically about atraumatic tears.

http://www.ncbi.nlm.nih.gov/pubmed/26209913

Why look, good evidence that traumatic rotator cuff tears do very well with surgery. I wasn't able to find anything comparing operative to nonoperative in traumatic tears, but I bet we see something about that in the next year or so given how things are playing out currently.

The rotator cuff study doesn't have any comparison group with PT over the year that was studied (from what is posted on pubmed, therefore it isn't level 1 evidence) or randomized. All the study says is that "younger patients with traumatic injuries" that are basically healthy athletes can do better without comparing to any control. Can you show me where they did a RCT compared to PT? How do we know these patients wouldn't have 80% improvement with just PT alone and the surgery did nothing to improve that? Younger, health athletes often improve just through their own trainers without needing surgery.

This is NOT level 1 evidence. All the pubmed reviews I see of anything positive for younger athletes are level 4 or so (case studies, non randomized/non comparison studies, etc)

Can you cite a study that makes this comparison in younger patient that shows level 1 evidence?

The meniscus REVIEW article you posted only discusses previous studies. Again, the one in the younger cohort (only one that shows any benefit, which is the vast minority of surgical cases) DOESN'T compare it to cheaper PT alternatives (that I can see).

None of this is "level 1" evidence since they aren't RCT with a placebo/alternative treatment comparison if not compared to PT. The studies I posted for older patients were LEVEL 1 with direct comparisons to PT.

What percentage of rotator cuff sugeries are done on older patients vs younger ones? What abut meniscus? From my experience, the vast majority of surgeries are done in the OLDER atraumatic cohort that ARENT athletes, that has been proven with level 1 evidence to NOT work better than PT.

In fact, the PRP comparison studies are showing better efficacy for these problems than traditional surgery.

 

[DrCommonSense]

Good post.

Nice post!

I do think you are fundamentally misrepresenting the issue at hand here.

The crux of the issue with EBM and IPM, is not that their is "insufficient evidence that IPM works" e.g. I don't know, the studies have not been done, maybe if we do some more studies we can prove the stuff works.

The actual issue is that there are a variety of negative studies published for many of the procedures (and their accompanying indications) we commonly perform. Therefore, we are not in a position to claim "absence of evidence does not imply evidence of absence" with respect to the evidence.

Hence, the strategy is to critique these negative studies. "Wrong patient selection, inappropriate technical approach, hidden confounders, etc.". This seems to be the logical approach, because, after all, there are a lot of positive studies for these procedures too!!!!

Which is to say, either you have to explain the negative studies away as I have indicated, or bail on IPM all together and take the position that the positive studies that have been published are biased/false and explain those away. After all, the negative and the positive studies both cannot be right!

So the devil really is in the details. And many of the studies are a very poor quality. And pain/pain patients are so complicated it is really tough.

In either case " The absence of level one evidence" does not seem to me to be the issue with our field.

I think the better case to be for IPM is quite simple: it kinda sucks but it beats the alternatives in terms of efficacy and especially in terms of side effects for the non-crazies. How many people are wrecked by opioids, NSAIDs, spine surgery, every year?...astronomical numbers!!!!! How about by ESIs/SCS/RFAs...extremely rare. (For the crazies, 101ns do nothing/psychotherapy approach is obviously the correct route. But I think it is pretty disingenuous to deny that there is a significant non crazy subset of the population with chronic pain.)

If I was in horrible chronic pain, I would rather have the best alternative even if it was very poor. So personally, I can honestly say, I would have an ESI if I had a raging radiculopathy... despite the fact that the published literature on ESIs is all over the place (which to me implies that it is probably a procedure with modest efficacy, if used in appropriately selected patients... If ESIs had excellent efficacy, I do feel that the state of the literature would be less ambiguous ).

But the actual reality of our situation, is that this is all infinitely complicated by the two facts that 1. Pain is a subjective, personal mental state which is impossible to objectively measure 2. IPM pays well. And those two facts can only result in one possible outcome given human nature: many IPM physicians are basically horrible people and unscrupulous and often fraudulent. Hence the increasing scrutiny in the field, which is really not deserved compared to other fields, based on the current state of the evidence. Which is what I think your original point was getting at.

This is all commonsense, but tough to keep it all in mind when you are staring a negative study in the face!

I know this is a long post, but I found these issues so confusing and discouraging prior to starting fellowship and during fellowship. Hopefully some of these thoughts are helpful to potential future IPM docs.

Good post.

However, the level of "integrity" is low in ALL of procedural medicine from cardiology to spine surgery. All procedural based physicians have large segments of their population that strongly overuse procedures for financial gain.

This is made worse when device companies that make stents, EP catheters, fusion devices, etc get involved.

 

[Stim4me]

Nice post!

I do think you are fundamentally misrepresenting the issue at hand here.

The crux of the issue with EBM and IPM, is not that their is "insufficient evidence that IPM works" e.g. I don't know, the studies have not been done, maybe if we do some more studies we can prove the stuff works.

The actual issue is that there are a variety of negative studies published for many of the procedures (and their accompanying indications) we commonly perform. Therefore, we are not in a position to claim "absence of evidence does not imply evidence of absence" with respect to the evidence.

Hence, the strategy is to critique these negative studies. "Wrong patient selection, inappropriate technical approach, hidden confounders, etc.". This seems to be the logical approach, because, after all, there are a lot of positive studies for these procedures too!!!!

Which is to say, either you have to explain the negative studies away as I have indicated, or bail on IPM all together and take the position that the positive studies that have been published are biased/false and explain those away. After all, the negative and the positive studies both cannot be right!

So the devil really is in the details. And many of the studies are a very poor quality. And pain/pain patients are so complicated it is really tough.

In either case " The absence of level one evidence" does not seem to me to be the issue with our field.

I think the better case to be for IPM is quite simple: it kinda sucks but it beats the alternatives in terms of efficacy and especially in terms of side effects for the non-crazies. How many people are wrecked by opioids, NSAIDs, spine surgery, every year?...astronomical numbers!!!!! How about by ESIs/SCS/RFAs...extremely rare. (For the crazies, 101ns do nothing/psychotherapy approach is obviously the correct route. But I think it is pretty disingenuous to deny that there is a significant non crazy subset of the population with chronic pain.)

If I was in horrible chronic pain, I would rather have the best alternative even if it was very poor. So personally, I can honestly say, I would have an ESI if I had a raging radiculopathy... despite the fact that the published literature on ESIs is all over the place (which to me implies that it is probably a procedure with modest efficacy, if used in appropriately selected patients... If ESIs had excellent efficacy, I do feel that the state of the literature would be less ambiguous ).

But the actual reality of our situation, is that this is all infinitely complicated by the two facts that 1. Pain is a subjective, personal mental state which is impossible to objectively measure 2. IPM pays well. And those two facts can only result in one possible outcome given human nature: many IPM physicians are basically horrible people and unscrupulous and often fraudulent. Hence the increasing scrutiny in the field, which is really not deserved compared to other fields, based on the current state of the evidence. Which is what I think your original point was getting at.

This is all commonsense, but tough to keep it all in mind when you are staring a negative study in the face!

I know this is a long post, but I found these issues so confusing and discouraging prior to starting fellowship and during fellowship. Hopefully some of these thoughts are helpful to potential future IPM docs.

You think IPM is full of fraudsters, look up the highest paid MDs on propublica. Optho injections for glaucoma are over the top and likely don't meet Statistical criteria. these guys are getting 2-5mm from Medicare alone. Maybe some of that is cost of medications, but their income are very high... Point is not to fight each other, rather push for healthcare competition and free markets. Let supply and demand determine cost and innovation.

 

[Ducttape]

Uh? Some of the most inspiring and intelligent people I've met in life are IPM physicians.

Yes. Like all fields, there are good and bad. Applaud the good, but do not overlook the errors of the bad.

The reason the other post was long and seemingly disjointed is because I was responding to 3 different posts in one.

To avoid confusion, let me just say that we are directly in control of our specialty and can influence decision- making and treatment in our specialty. I'm not going to tell a cardiologist what not to do, unless it is somehow related to chronic pain. That's what makes me a specialist and far be it for a, say, dermatologist to be a thought leader in chronic pain. Imagine the outrage.

(FYI the acc/aha guidelines does list grade A, B and C recommendations...)

Since we do not have level 1 evidence for anything in chronic pain, we must make do with what we do have and know. The best evidence does not seem to support IPM for a sizable portion of patients or conditions, with the possible exception of RFA (and apparently only when it done one particular technique - see other thread).

Does that mean that I think we should abandon Procedures? Far be it. Unfortunately for many patients, it is all that is offered by money grubbing docs as well as by some well meaning docs, who come to believe the cure is through the tip of a needle.


Sent from my iPhone using SDN mobile

 

[drpainfree]

EBM is the best tool healthcare insurance/administrators have to deny care, simple and easy.

If you are paying cash for procedures, do you really ask your doctor to produce double-blinded, randomized control study to support his treatment plan? It's reasonable to ask for doctor's opinions, clinical experience about the efficacy of a procedure, but if you try to ask me to produce RCT, level 1 evidence to support a procedure, I'd say find someone else.

DrCommonSense made a lot of good points that made sense. I'll just add another common sense statement that I heard many years ago,

There has never been any double-blinded, randomized control trial study to show parachute saves life, so why do you wear it? You can replace "parachute" with any other safety items that come to your mind, lifesaver jacket, airbag, etc.

So just because you don't have RCT study to back it up, does it mean you don't do it? Of course not. USE YOUR COMMON SENSE, instead.