What’s wrong with this picture?
Answer: A Lot!
This is one of the illustrations I created for my book; Sacroiliac Joint Pain: For Tens of Thousands the Pain Ends Here (Amazon; sijointpaingone.com). The book is written for the lay person with chronic low back pain secondary to a dysfunctional sacroiliac joint. It speaks to the thousands of people who either have this diagnosis and fail to get better with endless conservative treatments, to include injections, or never obtain an accurate diagnosis in the first place and just continue to suffer.
The obvious major problem in this picture is that the “patient” is at the bottom in the position of “least importance”. You can see that at the top in the position of “most important” are all the entities that make a profit for providing health care in America. This is our current reality in our now capitalistic profit driven health care system. Some feel that the patient would not even make it into the pyramid at all, but those at the top need patients to make this work for them. America is the only country in our industrialized world that has flipped its health care pyramid like this. Although this “flipped” pyramid reflects what is going on with sacroiliac joint surgery, I know that those in other fields of health care in our country will think this illustration looks all too familiar.
Contrast this with the picture below reflecting how patients with chronic sacroiliac joint pain were considered in our same America a long time ago in 1985.
That was the year that I began my orthopedic spine surgery practice and getting ready to meet my first very challenging sacroiliac joint pain patient. You can see that the patient in this pyramid is where I was taught they should be, at the top. The players in the levels below the patient were each responsible to the one above them. This was not a business “for profit” model. This was a medical “for patient” model that worked well and looked out always for the what was best for that individual for whom the entire system since Hippocrates (e.g. Hippocratic Oath) was built to serve. It was this model that was taught to me and my colleagues. We were expected to be the Primary Advocate for each and every one of our patients. All those functioning in each of the levels below the surgeon also seemed at that time to have desired the best possible outcomes for patients as their main objectives.
It was a “Camelot” time for medicine and surgery that many refer to as the “Golden Age of Medicine”. It is true that occasionally individuals could turn this system into one that was self-serving, but those kinks usually got worked out by the countless others who had not drifted from the prime objective; properly caring for and treating the patient. Today we witness a pyramid that has literally been turned upside-down due to the egregious manipulation of the entire medical system as we knew it in order to provide profit satiation for the few who now control it. This is truly an American dream come true for those that profit, but it is an American tragedy for tens of thousands of patients for whom no advocates remain!
I must say that I too was a player in helping to flip this pyramid of medical excellence. The slowly prevailing influence of industry and hospitals sinking their teeth into all that was once considered sacred was like the worm slowly dissolving its infrastructure until it could stand no more. It was easy to move along with the flow and accept the gifts of industry and a nice pay check from hospitals, while at the same time giving up more and more control over what actually happened to patients.
Another obstacle these patients encountered was a gross lack of medical education from medical schools and our esteemed national surgical educational societies about chronic sacroiliac joint pain. Low back and leg pain, which are the symptoms for chronic sacroiliac joint pain, had for years been solely attributed to only the lumbar spine resulting in a multibillion dollar industry having been built around that belief. This led to the creation of entrepreneurial surgeons working with industry to become partners for profits in this lumbar spine extravaganza. I personally know of one surgeon having been paid 77 million dollars by industry for his intellectual contributions to this effort. As the mantra “the lumbar spine causes all low back and leg pain” continued, this mania resulted in what seemed like endless profits. As a result, the severe chronic and disabling pain from the sacroiliac joint, that was also causing low back and leg pain, was just simply ignored. It is now known that up to 22% of all new low back pain is being generated by the sacroiliac joint. In the decades before this new information surfaced tens of thousands having this type of pain were either doomed to never have an accurate diagnosis and correct treatment or ended up having useless fusions of the lumbar spine that, not only failed to relieve their pain, but these fusions put more stress on the sacroiliac joints potentially making their pain worse. Others were considered to be just crazy.
It was during this time that several surgeons in America, who understood that the sacroiliac joint could cause this severe pain, were working on ways to address it surgically. Due to the lumbar spine industry’s financial inundation of the large medical societies in support of the lumbar spine causing all this pain, it was difficult for these surgeons to get their clinical and surgical papers on sacroiliac joint pain accepted for presentation at meetings. This had the effect of stalling the surgeon’s educational process concerning sacroiliac joint pain at the expense of thousands of chronic pain patients. As this trend progressed individual patients were slowly losing their surgeon advocates who had been bought off by industry.
The circumstance that made me take notice that the pyramid had flipped was that the average patient suffering from sacroiliac joint pain, who had failed all reasonable conservative therapies, did not fit into this new system. They had chronic pain, and surgeons weren’t educated to either diagnose chronic sacroiliac joint pain or operate on it if they did. The majority of these patients also had a lot of additional medical and socioeconomic issues. All these factors were causing them as a group to slow down this efficient low back pain surgical profit-making machine.
Ironically it was industry that ultimately pushed forward surgery for patients suffering from chronic sacroiliac joint pain. The year was 2008 when industry found a way to circumvent the entire Federal Drug Administration (FDA) by using an old trauma approach to fuse the sacroiliac joint. The difference was that instead of using two long lag screws, which did not work well to relieve pain, substituted their manufactured devices. At $10,000 per device and up to 50,000 of these surgeries predicted annually by 2020 it is not difficult to see that a potential “Blue Ocean” in surgical industrial sales could be a reality. Just to emphasize this point, there was one company doing this in 2008 and now there are twenty-two. Since the medical educational system for surgeons is continuing to teach nothing on this subject for the reasons discussed above, the only ones teaching surgeons how to put these devices into real patients are surrogates from industry. To make matters worse for the patients undergoing these surgeries, there is no standard method for choosing someone to operate on and no accountability for the surgeon to choose the appropriate patient for a sacroiliac joint fusion or to perform the surgery correctly. If the inappropriate patient is operated on or a complication occurs, the facts of such are easily buried and hidden in our current system; which protects industry from exposure.
The only good thing that is happening with all this is that there is more understanding that this joint can be severely painful and disabling as industry is making sure everyone knows this so their devices will be sold and used. The downside is that there is only one type of surgical treatment currently available; the one industry advocates, which might not be the best one. Surgeons are still not being taught by any reputable organizations or medical schools how to diagnose this condition, what conservative measures should be used first and how to select the appropriate patient for surgery. Also, even though different causes or pathology might exist that cause this pain, there remains only one way to address the joint surgically, which may not adequately address the pathological problem. Our current reality concerning surgery for this joint is that it is a “free-for-all” with no one in charge.
This situation is not going to change anytime soon. With our current for profit health care system (the only for profit health care system of all the industrialized nations on Earth) and literally no education for surgeons, outside of that provided by industry, the patients failing conservative treatments will continue to be either totally ignored by surgeons or, if operated on, will have no one looking out for them from the very organizations in America that exist to ensure the best possible care and safety for them.
This is a very timely subject in our country today and will become more so as time moves on. Though this article pertains to tens of thousands of patients in America, a small segment of our overall health care, it definitely carries a worrisome message for where our entire system is headed as industry and its associated politics take more and more control.
If you would like to become more aware of chronic sacroiliac joint pain and the true “real-life” disability it causes in America’s capitalistic for profit health care system, please visit my Blog at:
Bruce E. Dall, MD
Associate Clinical Professor
Western Michigan University School of medicine