Is There a Conflict of Interest?
Do orthopedists fail to suggest early-intervention or alternative scoliosis treatments because of a conflict of interest?
Why do orthopedists discourage alternative scoliosis treatments even if patients show improvement from them?
The medical approach to scoliosis treatment is to watch and wait, brace and then operate. During the “wait and see” period Orthopedists generally do not advise patients of alternative treatment options and some even laugh or scoff at the slightest suggestion. Patients are made to feel absurd if they want to pursue proactive or preventative treatments during this pre-brace/pre-surgery period and instead are advised to just sit idly while their curves progress until bracing or surgery become “necessary”. Some parents choose to research treatment and opt to try alternative treatments anyway and upon re-evaluation by their doctor are told they are wasting their time! Parents are belittled and made to feel negligent and are even harassed by their orthopedist.
If there are far less risks involved with alternative treatments, they are received while patients are in the “wait & see” period, and if these treatments show improvement to the patient’s scoliosis, then why is the medically community so against them?
In Scoliosis and the Human Spine, a book written by Martha C. Hawes, Ph.D, Dr. Hawes (a research scientist who herself has a large scoliosis) outlines what appears to be a “conflict of interest”. The conflict of interests center around the medical community’s lack of regard for an exercise based program of scoliosis care and correction.
There has been a tremendous movement in the country to screen for scoliosis. Why? So that it may be detected early in an attempt to intervene and treat before it progresses. But if the goal is early intervention, why are we “waiting”?
“...we have the wherewithal to diagnose spinal deformity at a Cobb magnitude of ten degrees or less, before it progresses to a serious problem that may cause pain, deformity, psychological dysfunction, and pulmonary problems throughout the patient’s lifetime. But instead of making an effort to diagnose the underlying condition and take steps to stabilize or reverse the curvature at this relatively benign state (and despite longstanding basic and clinical research consistent with the hypothesis that this is entirely feasible), patients and parents formally are told to do NOTHING: Just keep coming in to an orthopedic surgeon’s office every few months for another X-ray, and wait to see if it gets worse.” (Martha Hawes PhD, Scoliosis and the Human Spine, 2010)
DON’T TRY ANYTHING ELSE
Not only are patients advised to do nothing, but they are also discouraged from seeking alternative treatments or just informed that there is nothing that they can do.
“If individuals insist on searching out help on their own they are treated to condescension and insinuations that they are being irresponsible by trying ‘scientifically unproven’ treatments and refusing to accept the advice of professionals who know best (e.g. Keim 1987, Lonstein 1995a).”
If scoliosis screening is not geared at finding the curvature in it’s early stages and treating it before it progresses, then what is the intent? To merely refer more patients to orthopedic surgeons?
SCREENING LEADS to SURGERY
Since screening has begun there has been an increase in the number of scoliosis surgeries performed. If the goal was to decrease the number of adolescents subjected to spinal fusion surgery, then why are said patients only referred to orthopedic surgeons?
In our jurisdiction of New York, positive results of scoliosis screening can only be reported to pediatricians or orthopedists. By law, the schools nurses are prohibited from referring students to exercise based scoliosis care programs!
Since screening has been mandated the average curve for which surgery is carried out decreased from a Cobb angle of 60 degrees to a Cobb angle of 42 degrees (Lonstein et al. 1987). This was done as a means to operate sooner rather than later under the assumption that moderate curves will inevitably become severe curves but, as Hawes points out, “there are a lot more moderate (42° curves) than severe (> 60° curves) curvatures in the population”.
SURGEONS WOULD BE PUT OUT OF BUSINESS
“...if proactive therapies were found to be effective, orthopedic surgeons would be put out of business of spinal fusion surgery because there would be no progression to levels where such intervention might be warranted.” (Hawes 2010)
Why isn’t there more research on alternative treatments to scoliosis? Why don’t insurance companies cover these treatments?
ORTHOPEDISTS LOVE TO DO SURGERY
There are many upsides to performing spinal fusion surgery as opposed to other forms of surgery. Especially since, for many, the surgery is elective and most of the times the surgery is arguably “cosmetic”.
“Orthopedists as a group relate the degree of satisfaction in their practice to the amount of surgery they get to do, and elective reconstructive surgery like spinal fusion (implanting rods in the spine for scoliosis) is at the top of the list: High-skill, high-tech, very costly, covered by insurance, and no need to get up in the middle of the night to to set messy fractures after car wrecks and suicide attempts (Clawson 2001, Heckman 2001).”
SOME ORTHOPEDISTS ARE PAID TO DEVELOP TECHNIQUES & DEVICES FOR SCOLIOSIS SURGERY
There is the added bonus of money and grants received by selected “Leading” surgeons by the companies that supply the instrumentation they use during spinal surgery.
“..some scoliosis surgeons receive royalties and research grants from the biomedical companies who make the ever-evolving array of spinal implantation devices (Shufflebarger, 2001).”
What is an even more alarming is the rate at which these surgeries fail and require further medical intervention in the form of secondary surgical procedures, known amongst orthopedists as “salvage surgeries”. This surgery can hardly be called “elective” as patients experiencing extreme pain and impairment often are left with no alternative but to undergo further procedures.
“What is more, the worst that can happen is that the surgery will fail (as it does, often), and additional costly, elective reconstructive surgery covered by insurance (or the personal savings of desperate parents) will be required. Such ‘salvage’ surgeries cost $100,000.00 or more.” (Hawes 2010)
TOO MANY SURGEONS
Another major concern in the field of spinal fusion surgery is the large increase of orthopedic surgeons operating within the United States.
“The ratio of orthopedist to U.S. population has increased, predictably, from 1 surgeon per 110,000 people in 1941 to 1:25,000 in 1980 to 1:15,150 in 1999 (Clawson 2001). Surveys have shown that when the ratio increases to 1:15,000 or more, there is a significant increase in the number of operations being performed per 100,000 people, with concern that more elective surgery is being done than necessary.” (Hawes 2010)
The concern being that, in some regions, there is literally “not enough elective surgery to go around”. Shockingly, the author writes that spinal fusion surgery for teenagers with scoliosis was actually advertised on the radio in California in 2001.
“An Appearance of conflict of interest does not necessarily mean a conflict exists, and the vast majority of scoliosis surgeons undoubtedly are conscientious souls with a compassionate interest in their patients’ welfare which overrides issues of personal gain. Indeed, leaders in the discipline have taken a strong stand in favor of the urgent need to establish and enforce clear ethical guidelines (Shufflebarger 2001).”
This is not to say that orthopedists or orthopedic surgeons are to vilified for their practices. As Dr. Hawes also points out, one of the greatest contributors to scoliosis research, the Scoliosis Research Society (SRS), is comprised of several hundred orthopedic surgeons. Not only do they conduct research to better understand and treat scoliosis, but in addition they report issues and dilemmas within the field of surgical intervention for scoliosis.