Blog Post

Healthcare Upside/Down: Those Aren’t the Droids You’re Looking For

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ECG’s radio show and podcast, Healthcare Upside Down, offers unfiltered perspectives on what’s working in US healthcare and what’s not. Hosted by ECG principal Dr. Nick van Terheyden, each episode features guest panelists who explore the upsides and downsides of healthcare in the US—and how to make the system work for everyone.

It’s an unforgettable scene from an iconic film. In the original Star Wars, Jedi Master Obi-Wan Kenobi approaches a desert spaceport with his young protégé, Luke Skywalker, and two droids—targets of an intergalactic dragnet set up by the evil Empire. The quartet is stopped by a squad of Imperial stormtroopers who, by all means, should recognize the mechanical fugitives. Looks like the gig is up.

Not so fast…

“These aren’t the droids you’re looking for,” Obi-Wan says placidly, with a subtle wave of his fingers. “These aren’t the droids we’re looking for,” the commanding trooper agrees, allowing the group to move along.

In a way, something similar occurs with musculoskeletal (MSK) care. No, orthopedic surgeons aren’t bamboozled by Jedi mind tricks. But when patients complain of joint pain, physicians often don’t recognize the true source of the problem.

MSK disorders—any injury or disorder involving the muscles, nerves, tendons, joints, cartilage, and spinal discs—are the number one source of spending for most health plans year over year. Back pain is listed as the top chronic medical problem worldwide by the WHO, and arthritis is the most common cause of disability in people aged 65 and older.

Many patients who present with joint pain eventually have a joint replacement. But surgery might not be the best option; studies put 40% of patients being misdiagnosed. Some of these problems don’t require surgery, and the pain can be eliminated with exercises.

“When a hip replacement is necessary, it is a wonderful surgery,” says Mark Miller, co-founder and president of Integrated Musculoskeletal Care. “The problem is, there’s too many of them being done. And often, they’re actually being done when it’s not even the pain generator. In other words, they’re replacing the wrong body part.”

Mark has been a clinical practitioner for more than 30 years, and his company uses a standardized care model intended to eliminate the misdiagnosis of MSK disorders. On Episode XVIII of Healthcare Upside Down, Mark talks about the need to expand access to the best available care for MSK injuries and pain. Here are three takeaways from our conversation.

A case of misdirection.

When a patient presents to a clinician with an apparent MSK problem, the focus of treatment is often aimed at the body part where the pain is found. While a doctor may initially prescribe a course of physical therapy and other noninvasive remedies, many of these patients end up having joint replacement surgery.

But in the case of hips, Mark says the problem often originates not in the hip but in the back or spine. “A landmark paper came out [approximately] two years ago that looked at a consecutive case series of shoulders, hips, and knees where the diagnosis was along the hip joint,” he explains. “And what they found was 71% of these patients actually had a lumbar spine problem that was the main driver of the pain and the lack of function. And when that was resolved, the patient no longer had hip problems.”

So why do so many patients go under the knife? In part, because that’s the way it’s long been done. Physicians must do what they feel is right, of course, but not enough clinicians consider alternative diagnoses. “The image says [the joint] doesn’t look well, and the orthopedic surgeon is being asked to perform surgery, so that’s what they’re going to do—replace the hip,” Mark says. “Clinicians, whether primary care, physical therapy, even orthopedic surgery, don’t seem to be well versed in fully screening out the lumbar spine in the presence of a hip problem or the cervical spine in the presence of a shoulder problem.”

Benefits for patients.

Such screening could save some patients the trouble of undergoing invasive surgery. And with targeted exercise and self-management, positive outcomes can come quickly.

Mark recalls a golf pro who was referred to him some years back. The golfer was about to have rotator cuff surgery, which would be followed by a months-long rehab that could affect his livelihood. “He wouldn’t have been able to lift the club,” Mark notes.

“I screened his shoulder and could see how any clinician would look at that and say, ‘no doubt about it, that rotator cuff is shredded,’” Mark explains. “But when I screened his cervical thoracic region, within 15 minutes, he was 50% better. And within three visits, he was 95% better and playing golf again.”

Completing the training.

The solution, according to Mark, begins in medical school, and teaching primary care physicians to more accurately diagnose the causes of their patients’ joint discomfort. “Primary care has to be better trained,” Mark declares. “Primary care has access to the majority, and they have to make a decision as to where these patients go, and their training is minimal in that area. If we train primary care how to better triage musculoskeletal, and we teach conservative care clinicians to a standard of how to examine these patients, that’s the solution.”

Of course, identifying the solution and executing it are two different things. “You can imagine the barriers to implementation that range from training, to ego, to finance, etc.,” Mark acknowledges. “We have a solution, and every organization we’ve implemented it in has been successful. The problem is, it’s hard to get into these organizations, because change is not easy.”

How can your organization rethink treatment for musculoskeletal disorder care?

Mark talks more about nonsurgical orthopedic care and the data behind his methodologies.

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