Journal of Neurological and Orthopaedic
Medicine and Surgery
Charles F. Xeller, MD
Editor in Chief
The following editorials reflect the opinions and views of the Editor and are not intended to represent the official position or policy of the AANOS or its Board of Directors.
Editorial Posted (12/17/19)
Two Thoughts to Consider Regarding Pain and Its Perception
The Irony of Chronic Pain
Acute pain has a purpose for living organisms. It signals injury to a body part and alerts that a system of the body has gone awry. Chronic pain has no defined purpose and there is speculation that chronic pain should be considered a disease in its own right.
Most body organs will “switch off” when damaged. However, in chronic pain the situation may be reversed, with the nerve “switching on”. The ability to treat this condition, has become one of the greatest frustrations in all of medical science. That is certainly apparent in the now infamous “Opioid Crisis”. Initially opioids were used sparingly, generally in the treatment of acute pain following a surgical procedure or in the treatment of cancer. However, in the late 1990s, many pharmaceutical companies cited them as a long-term solution to pain. They advocated that these drugs were perfectly safe to use and rarely addictive to the patient. This has not been found to be true. Purdue Pharmaceutical Company paid some 600 million dollars in fines and penalties in 2007 for marketing OxyContin with fraudulent claims.
In the last 15 years, it has been discovered that many patients using opioids became rapidly addicted and the number of drug related deaths escalated to a considerable degree. In the last 15 years, it is estimated that some 250,000 Americans have died of opioid overdose. At the present time, the population of the U.S. is but 4% of the world total, yet this country consumes 80% of the opioid medications. About 2 million of the American population is estimated to be addicted to these medications.
Ironic that at this time, the pharmaceutical companies (who have helped to create the problem), are now manufacturing medications to counter and alleviate the side effects of opioid overuse. The industry is now profiting from medications designed to make the addicted more comfortable.
Here is another satirical irony of this problem – the number of organ donors has increased from opioid addicted individuals as this opioid epidemic continues.
Pills and Their Colors
It is certainly accepted, that in certain instances, placebos do work in alleviating pain. In the modern medical use of drugs to alleviate pain, placebos are tied to the concept of “free analgesia” (cognitional modification of pain). Modern science, has no idea as to why placebos provide benefit to individuals in pain. In fact, in many instances, placebos may be effective even when the patient knows that they are “sugar pills”. In has been shown that colored pills provide better pain relief than white pills. Red pills also are found to work faster than non-colored pills. And blue and green tables have been shown to provide a more soothing benefit.
So, like Neo in the movie, The Matrix, if given the choice you may want to opt for the red pill over the blue.
Editorial Posted (9/21/16)
As the Presidential Election of 2016 looms near, there has been some concern over the health of the respective candidates of the Democratic and Republican Party. There has been speculation of obfuscation and of not revealing what would be deemed to be important information. It is my opinion, that the voting public of the United States certainly should be made aware of the health of the candidates and the impact of any medical conditions on the ability of the individuals to govern this country.
Mr. Trump (now 70), if elected, would have the distinction of being the oldest individual elected to the Presidency. Apparently his release of medical records consisted of a four paragraph doctor’s noted, written apparently while Mr. Trump waited in his car. To paraphrase, the doctor stated” that he would be the healthiest individual ever elected to the presidency”. I would say this is NOT very informative.
As for Mrs.Clinton (now 68) there has been recent concern over a recent abrupt exit from the 911 annual memorial event in New York City. Potential reasons listed include: overheating, residual effects of recent pneumonia, seizure, or transient ischemic attack. It is documented that her past medical history does record a deep venous thrombosis in 1998 and 2009, an elbow fracture in 2009, and a concussion in 2012. Regarding the recent event, there has not been a formal report from her physician.
Medical issues have clouded other prior campaigns also, which have been less than forthcoming. It has been reported that Dwight Eisenhower, worked diligently to mask his medical issues during his run for the Presidency as well as during his term of office. In 1949, his cardiologist deliberately misdiagnosed a myocardial infarction.
John F. Kennedy (the youngest man to hold office), also worked hard to conceal his medical conditions including a 19 day hospitalization before his winning the White House. On several occasions, Kennedy denied that he had Addison’s disease (adrenal insufficiency).
As for Ronald Reagan, during his re-election campaign in 1984, there was concern about his age and mental fitness. A formal diagnosis of Alzheimer’s disease was not made until years after leaving the office, however, his family later reported in 2011 that there were early signs of dementia during his 1984 run to office.
All of this is very thought provoking. In my opinion, appropriate candidate behavior would be to be forthcoming and truthful as to medical conditions. To quote the press mantra, “the public has a right to know.”
Editorial Posted (9/14/16)
HOW MEDICAID FAILS THE POOR.
The Medicaid Program was created in 1965 through the Social Security Act in 1967. Medicaid was created by the US Federal Government to provide health care services to people with low incomes who cannot afford health care services or health insurance on their own. Each individual state manages their Medicaid services and programs. The cost of the 500 billion dollar program is anticipated to increase to 890 billion dollars by 2024 according to the Centers for Medicaid and Medicare Services. Yet, does more government spending mean better care for the Medicaid beneficiaries?
First, there is the problem of finding a doctor. Some 55% of physicians in major cities refuse to take new Medicaid patients. Reasons given include low reimbursement and increased potential for malpractice litigation (low reward, high risk). The Department of Health and Human Services reports in 2014 that 56% of Medicaid primary-care doctors and 43% of specialists were not available to new patients. Because of restriction to entry care, Medicaid patients will tend to use the emergency room as a doctor’s office for non-urgent care.
If a Medicaid patient does manage to see and have treatment with a physician, the outcomes are generally worse than those under private insurance. Comparison of those sets of patients show more inpatient hospital mortalities, more complications from surgical procedures and longer length inpatient hospital stays.
Secondly, outcomes of treatment have NOT been found to be better when compared to a group of patients without insurance. Reasons that have been cited include Medicaid’s various restrictions on drugs, specialists and newer technology. At this time, in the Medicaid program there is absolute government authority over payment to doctors and authorization of treatment option.
Poor Americans in the Medicaid program are placed in an inferior, low value healthcare program. For example with a simple non-displaced ankle fracture that would be treatable with a cast boot, the only option for those patients is a posterior plaster or fiberglass splint.
What are possible Medicaid program reform options?
- Individual health care savings accounts.
- Mandatory co-payments for non-emergency use of emergency rooms.
- Rewards for healthy behavior.
- Expansion of hospital outpatient clinics with incorporation into Residency Program training.
- Mandatory practitioner attendance and participation 1-2 days per month in hospital outpatient clinics as a requirement for State Licensure.
Editorial (Posted 11/8/15)
TO BE OR NOT TO BE? THAT IS THE QUESTION.
What has the Art and Science of Medicine come to, when the Value of Death is more important than the prolongation of Life?
Physician assisted suicide in the State of Oregon, was legalized some twenty years ago. Since that event, more than 850 individuals have been authorized to take their lives by the administration of barbiturates. Physician assisted suicide is also legal in the States of California, Washington and Vermont.
The Oregon Death with Dignity act sets certain requirements – a patient may request lethal drugs only if the individual has a documented terminal illness and less than 6 months to live. The patient must be certified to be of sound mind to request the prescription for the lethal dose of medication. Also two doctors must confirm the terminal condition and that the patient only has some 6 months to live. Two witnesses, one a non-physician, must confirm that this is the request of the patient and the patient must make a second request after 15 days.
Just for consideration, what if a patient has cancer and one oncologist is of the opinion that the patient is indeed terminal with less than 6 months to live, and then a second is more positive about prognosis with various treatment options?
The law also states that the individual be referred for psychological examination if the doctor suspects that there is depression or mental illness. However, last year (2014) less than 3% of the 105 patients who died under the auspices of this law were actually referred for a psychological exam. It almost seems that doctors are “pushing” the patients down the road of assisted suicide.
The Death Certificate will list the cause of death, as the terminal illness. Why is that? Doctors are falsifying a Death Certificate by not listing suicide as the cause of death as required by State law.
It should be noted that there is a distinction between euthanasia and physician assisted suicide. Euthanasia is performed by the physician or another person administering the lethal dose of medication, while physician assisted suicide requires the patient to administer the medication.
Is life more expensive for individuals than death? In the State of Oregon, many medical treatment services and prescriptions for medical conditions are NOT covered by the Oregon Health Plan. Yet, physician assisted suicide is covered financially by the State’s Medicaid program (it is free, covered by collection of tax dollars from the residents of Oregon). Is there not a real value to an individual’s life, no matter how debilitated one becomes?
As a society, where have we fallen to, when we lead patients into physician assisted suicide, rather than work to provide access to appropriate drugs, palliative procedures and care, and better access to hospice treatment?
Previous Editorial (Posted 4/6/15)
HEAD ON BODY OR BODY ON HEAD ?
I await with anxious anticipation, the upcoming 2015 Annual Meeting in Annapolis and especially the lecture to be given by our Keynote speaker on head transplantation. Such a procedure could certainly be a great step forward in medical progress.
There are certainly ethical issues that arise from such a procedure. Consider; who is the donor and who is the recipient, such the title of this piece of reflection, “Head on Body or Body on Head?”
I immediately jumped to the conclusion, that the body is the donor and the head is the recipient, however my sixteen year old daughter is of the opinion that the head would be the donor, as the soul resides in the heart. That gives pause, as one considers the metaphysical concept of the soul and where it resides.
Consider the following scenario for your thoughts. Mike sustains a gunshot to the head. He is placed on immediate life support, however the EEG is flatline. From a medical perspective, he is technically dead. Joe, falls down a flight of stairs and suffers a cervical injury that has the end result of paralysis from C4 caudad (from the neck down). Joe is cognizant but he will be a quadriplegic. The decision is made to transplant Joe’s head onto the body of Mike. Now, who is the donor and who is the recipient? By my reasoning, Mike was dead. Therefore his body is the donor to the recipient head of Joe (consider the analogy of a corneal transplant). However, my daughter argues that the head is the recipient of the body. She makes several points to consider: 1. The perfusion of the head, will be from the body’s heart and circulatory system. 2. Cells for any regeneration of tissues will be nourished by the body, and the majority of the stem cells will originate from the body, and lastly, 3. The soul will reside in the body and not the head.
Makes one consider, what makes a person a person? Is it the functioning brain? Is it the total compendium of the entire body (and head)? If there is a soul, where does it reside?
What would be the name of the individual after the transplant surgery? Would it be Mike or Joe? A member of my staff joked that he would now be Frank (Frank N. Stein)! Would you consider the person to now be Mike-Joe or Joe-Mike? The case could be made that the individual is now a chimera. These are certainly valid points to consider.
Such a stupendous operation certainly gives thought to other questions. Is such an operation, a consideration for extending life, with transplantations of old onto young? Could it be considered a valid treatment for transgender psychological pathology (for example, a genotypical male, who feels that he is a woman trapped in a male body)?
There are certainly, considerable technical obstacles (surgical, immunological, medical life support) to overcome before any such procedure would be tenable in humans. There are also considerable ethical issues that need to be carefully thought about.
It brings to mind the vignette of a line of individuals waiting to get into heaven, with Saint Peter the guardian of the Gates of Heaven. A person in a white lab coat wearing a stethoscope strides to the front of the line and walks right in. Someone in line asks, “Who was that?” The reply, “Oh that is God, he likes to play doctor from time to time.”