There are several concerns that are recurrent themes each year:
The patients who receive a procedure even though they are poor candidates
Patients who are encouraged not to mobilize as part of case building maneuvers
Patients who use injury in a futile attempt to solve longstanding personal problems
Addressing just the first theme, it has always concerned me that there is a disparity between those who receive procedures and those for whom procedures are clearly contraindicated.
I routinely see patients for spinal column stimulator implant candidacy. From a psychological standpoint, greater than 95% are very good candidates, and of the remaining five percent, all that is lacking is a better understanding by the patient as to their responsibilities after the trial and their options if the implant is not as effective as they had hoped.
However, a few patients are decidedly poor…actually horrible…candidates. They are abusing street drugs, they are selling their prescription drugs, and a host of other issues.
In a recent case, the patient was frankly schizophrenic. He was delusional, had recurrent hallucinations and was emotionally labile. Although he was obviously working when injured, he was one of the walking-wounded of mental health. He was clearly dysfunctional and now, without the structure of work, was more suitable for an inpatient stay in a mental health facility than a stimulator implant candidate.
However, his physician was sorely disappointed in this outcome. She wanted to know if the patient could be successfully treated to the point where he would be able to tolerate the stimulator trial. Even with further clarification, she could not separate from her own (largely financial) goals for the implant and the fact that the patient was likely to have frankly psychotic thoughts about anything put in his body…especially ones with wires.
Interestingly, the patient did not want the procedure. He was actually increasingly acceptant that he would have back pain.
Sometimes, it is not the patient who needs the education. And sometimes no amount of education will dissuade someone from wanting to perform a procedure.