Values & Chronic Pain Management

I recently came across this blog post in my reading and thought that it would be a good conversation starter. In the post, Mark MacLeod, MD, raises the point that we need to have an on-going discussion about values in healthcare. Dr. MacLeod is on to something here. In his piece, Dr. MacLeod is writing within and about the Canadian healthcare system. However, his point is applicable to any country’s healthcare system. We need to engage in a communal dialogue about our values when it comes to what we should (or should not) do with our healthcare systems.

In such a discussion, values play at least three important functions. First, they serve as guides for our behavior when actively engaged in an activity. In this sense, we might ask whether our behavior is in accordance with certain rules or norms we live by. Second, values serve as goals when engaged in an activity. They show us what we should be shooting for. In this sense, we might ask about the goals that we are trying to bring about when engaged in some activity. Third, values serve as a means to judge how good of a job we did, once we engaged in some activity. They allow us to compare what it is we completed with what it was we were trying to complete. This comparison is the distinction between what is (i.e., what we did) and what should be (i.e., what we were aiming for).

As we go about making our healthcare system(s) better, what values do you think should guide our behavior? What values should we try to attain when making our healthcare system(s) better? What values should we use when taking stock of our healthcare system(s) – i.e., how we are doing right now or into the future?

Taking these questions closer to home, what values should guide our behavior when managing chronic pain? What values should guide us when trying to make the quality of chronic pain management better? What values should we use to judge how well we manage chronic pain? It would be interesting to hear from you. How might you answer these questions?

It would be interesting and helpful to engage in a dialogue about your values when it comes to chronic pain management, and how they might be similar or dissimilar based on your personal or professional experiences, and what country you might be from. Of course, I would also ask that the values of civility, politeness and respect guide our conversation.  

Here are mine.

Professionalism

Call me ‘old school’ but I think healthcare providers should do what they do because primarily they want to help people. Loosely, the definition of a profession is a vocation that involves providing a humanitarian service to others. The primary focus of a profession is that it is a job that helps people: a job that aims to make sick or injured people well (a healthcare provider); a job that teaches people (an educator); a job that protects people and their property (police officers & firefighters); and so on. While a sense of professionalism has remained strong in the professions of education and first responding, professionalism seems to be waning in healthcare, especially over the last thirty years in the U.S. Indeed, in certain circles, talk about how we should be in it to help people can sound quaint.

In the U.S., hospitals, clinics, and provider groups have become corporatized (if I can make up a word). Over the last thirty years, many such groups have become actual corporations. They have shareholders and CEO’s who are not healthcare providers, but rather individuals with significant business experience and training. Of course, some hospitals, clinics, or provider groups have maintained their non-profit status,  but even most of these have become corporatized in their behavior. The bottom line is as important (and sometimes more important) as the health and well-being of those they serve.

The values of corporations and the language of production has permeated our healthcare system in the last thirty years in the U.S. Hospital, clinic, and provider groups, -- even individual providers – are measured not by how well their patients are, but by how productive they are. Monthly quotas and productivity reports are now standard fare for healthcare providers.

Now, don’t get me wrong. There is nothing wrong with corporations. They serve a great function and their primary function is to make money. Again, there is nothing wrong with making money. It’s a great thing.

It’s a matter, however, of what is most valued. As healthcare providers, are we primarily in the field to help people or are we primarily in the field to make money? Are we primarily a profession or are we primarily a business? In the last thirty years in the U.S., we have become primarily a business.

I think we should primarily be a profession.

What difference does it make?

On a societal level, it matters because when healthcare providers are structured and therefore act as a business it leads to a lot of healthcare spending that we all end up paying for in our premiums. Hospital, clinics, and provider groups – even most individual providers – get paid based on productivity. The more healthcare providers treat and test, the more they get paid. Subsequently, the more healthcare providers treat and get paid for it, the more we, as a society, have to pay for it through our insuranace premiums. By incentivizing treatment and testing, we as a society foster an expensive healthcare system.

On the individual level, it matters because it creates a certain tension between you and your healthcare provider. As a patient, you expect your healthcare provider to be a professional – to act in your best interest. However, the healthcare system incentivizes your healthcare provider to act in his or her best interest. Therein lies the tension.

Patients feel it everyday. I hardly have a day go by when I don’t hear from a patient about his or her resentment towards healthcare providers, particularly chronic pain management specialists. They tell an all-too-common story: they have been treated over the years with countless procedures, surgeries, and tests, and have never gotten considerably better; they continue with intolerable levels of chronic pain and disability; subsequently, it has dawned on them that maybe it wasn’t their best interests that were served in this long history of care.

Providers too feel it, at least some of us. They remain concerned about the administrative focus on the bottom line. It’s not uncommon to talk among ourselves and question, “Didn’t we get into the field to help people?’

Truth be told, though, not all of us resent it. As you can see in the news most everyday, many hospital, clinic, and provider groups fight tooth and nail to maintain this system of incentivizing treatment and testing. They would have a lot to lose if it were given up.

One simple step towards solving this tension that patients can make is to demand to see healthcare providers who are salaried. It might take some looking around, but some of the most prestigious healthcare institutions in the U. S. pay their providers on salary, rather than production.

With some notable exceptions (including healthcare providers), most professions are salaried. Teachers don’t get paid based on how many students they teach. Police officers don’t get paid based on how many people they pull over. Fire fighters don’t get paid based on how many fires they put out. Why? It’s because we, as a society, want them to maintain a focus on the good of others. We don’t want to put them in a position of having to choose between their own self-interest (i.e. their livelihood) and the interests of those they serve.  We want assurance, for instance, that the police officer pulls someone over because it was the right thing to do, not because the police officer would stand to financially profit from it.

When you think about it, professions are jobs that have a certain amount of power in society: healthcare providers, teachers, police officers, fire fighters, and so on, have been given power to influence people – hopefully for the good. With this power, we want them to exercise it for our well-being, not their own. We don’t want their self-interest to corrupt the power that society has given them. We need them to primarily serve society’s interests, not primarily their own. As such, society reimburses them through a salary system that keeps their focus on us.

Similarly, you could demand to see healthcare providers who are reimbursed through a salary and, as such, are not incentivized to treat and test you. You will have greater assurance that your healthcare providers are making recommendations based on what they think are in your best interest, not theirs. In other words, you will have a greater assurance that your healthcare providers are primarily acting out of their profession (and not primarily acting as a business).

Evidence-based healthcare

As we attempt to make chronic pain management more helpful, I think we should have as a goal to make it more effective.

How would we do that? A lot of healthcare is done out of tradition (it’s how we were taught) or because it is profitable. But don’t we deserve a higher bar? Indeed, healthcare providers should make recommendations based on what is most effective – not on what they have always done in the past or what will make them the most money.

If you had cancer, you would want the most effective treatment, right? And if the first treatment didn’t work, you would go on to the next most effective treatment, right? Shouldn’t we do that with all health conditions?

The practice of engaging in the most effective treatments first is called evidence-based healthcare, or empirical based healthcare.

How do we determine what is most effective? Well, we need a way that is rigorous – we wouldn’t, for instance, want to decide by just flipping a coin. We would want to put it to a more rigorous test. The testing process would have to involve more than one patient or even a few patients.  Why? It’s because most any treatment works for some small percentage of people. It’s called the placebo effect. So, we need to see what works for most people. In our society, we do this with the scientific method and specifically employing a method of testing called the ‘clinical trial.’ The most rigorous testing occurs when we put together a large number of clinical trials into what’s called ‘a meta-analysis,’ which gets the overall average outcomes of all the clinical trials. The results of clinical trials and meta-analyses are thought of as the most valid and reliable information about the effectiveness of a particular therapy.

So, what difference does empirical-based healthcare make?

On the individual patient level, if you value what science tells us is most effective, then you are more apt to pursue those treatments and therapies that are most effective. Educate yourself as to what is most effective in chronic pain management. The ICP attempts to provide this information on many of its content pages. Ask your healthcare providers whether they know of the clinical trials and meta-analyses that support their recommendations. Don’t be satisfied if they respond with something to the effect of either, “This is how we have always done it” (i.e. tradition) or “We’ve had some good luck with this procedure” and then telling a story about how someone got better with it (i.e., not rigorous enough testing).

On the societal level, when we use the value of empirical-based healthcare, we make chronic pain management more effective for most patients. Patients would be less apt to get recommended procedures that are known to be ineffective (as defined by the afore-mentioned scientific methods). It might also lower society’s health insurance costs (in the form of premiums) because insurance companies would be less apt to pay for procedures and therapies that are known to be ineffective. Less costs to insurance companies means less cost to us, those who are insured.

Integrity

I think integrity is also a value that should guide us as we attempt to change how chronic pain is managed (or change the healthcare system for the better, more generally).  As a society, we need our healthcare providers to walk the walk, not just talk the talk.

Few hospital, clinic, or provider groups would disagree with my three values. Nonetheless, many would fight (and do fight) the consequences of them if these values were really used to guide how we managed chronic pain. There is big money involved, at least in the U. S. Any change in a system, of course, leads to some winners and some losers. If we changed how chronic pain is managed by focusing it on only treatments that have empirical evidence supporting their effectiveness, certain hospitals, clinics, and provider groups would stand to lose a lot of money. Right now, some of the most profitable procedures in chronic pain management are also the most ineffective (as defined by the afore-mentioned scientific methods). Moreover, many individual providers in chronic pain management are paid based on production. A change to a salary system would almost surely reduce an individual provider’s income.

However, it would also necessitate a return to our profession. Healthcare providers would have to be in it, seeing patients day after day, because they primarily want to help people. It is why most of us got into the field in the first place. Our practice, then, would be true to our values. That wouldn’t be such a bad thing in my book.

What are the values that you think should guide chronic pain management now, and how do you think we might change it for the better in the future?

Author: Murray J. McAllister, PsyD

Date of last modification: May 20, 2013