Kris Radcliff, MD, is a fellowship-trained spine surgeon with Philadelphia-based Rothman Institute.
Dr. Radcliff began his practice, which focuses on minimally invasive spine surgery and artificial disc replacement, at Rothman in 2009 after completing a combined fellowship in orthopedic and neurological spine surgery at Thomas Jefferson University in Philadelphia.
Here, Dr. Radcliff discusses how his patient population has evolved over the decade, changing attitudes toward opioids and how the internet has affected the patient-physician dialogue.
Question: How has your patient population evolved over the past 10 years?
Dr. Kris Radcliff: I definitely see more people who are willing to have surgery. More and more patients are asking for specific procedures, which didn't really happen when I first started my practice. The most common thing that patients request is minimally invasive surgery. Before that it was laser surgery and before that it was disc replacement. So, it's clear that patients are getting information about procedures from sources other than medical providers.
Most commonly they read about specific procedures on the internet. However, the challenge is that patients aren't always aware of their precise diagnoses. Additionally, patients are not aware of the relationship between their diagnoses and appropriate procedure. For example, patients may not realize that the presence of spondylolisthesis in addition to a disc herniation precludes an artificial disc replacement. Although patients receive their MRI reports, it is difficult to interpret the information on the MRI report without a context about the prevalence of asymptomatic degenerative changes and the various clinical syndromes such as myelopathy. Patients don't have a lot of insight into understanding the subtleties of different diagnoses.
The other significant recent challenge is the blurring of the lines between interventional pain providers and spine surgeons (orthopedic surgeons and neurological surgeons). There are some surgeons who do epidural injections and discograms. Likewise, there are some interventional pain management providers who are doing endoscopic discectomies, placing interspinous and interlaminar implants, performing sacroiliac joint fusions, and even placing pedicle screws in some cases. Other specialties such as hand surgery and cosmetic surgery have similarly worked to define their scope of practice. It is in the public's interest to work on defining what training is necessary to properly, safely and reproducibly do certain procedures on the spine.
Q: Has the internet and patient self-education presented a new challenge to physicians that may not have existed a decade ago? How has this impacted the patient-physician dialogue?
KR: Absolutely. I'm now discussing options that patients learn about on the internet and almost talking patients out of procedures that they've requested. The challenge with internet marketing is it doesn't always paint a clear picture of the reality of surgery risks and benefits. At the Rothman Institute, we track our clinical outcomes closely and thus we have our own internal data that we show patients in terms of our outcome. It's hard when I'm asking patients to compare internet marketing information that focuses on positive outcomes against actual clinical data that presents a balanced picture of surgery including the risks and expected outcome. It's difficult to hear about what can go wrong but it's a critical part of what patients need to be advised of.
Q: The opioid crisis is a hot topic at the moment. What are your theories on how physicians and healthcare organizations can help tackle the opioid crisis? How has your patient population's attitude toward opioids changed?
KR: I've seen a tremendous change in the public attitude toward opioids. New patients coming in now with acute pain are saying that they don't want opioids, and they're concerned about their effects and other potential issues. That is a stark contrast to when I started my practice. Just 10 years ago, patients were expecting, and almost perturbed, if they were not given opioids. Certainly, I've always been reluctant to prescribe opioids and the issues of tolerance and addiction are well described in medical literature. The public attitude has changed significantly and I think it's a very positive thing.
The other thing is, at least in New Jersey, the state medical board made a rule that new opioid prescriptions can only be a five-day supply. There are criteria for subsequent prescriptions to be filled. That has helped me to explain to patients that indeed the entire medical community is concerned about opioids and that my reluctance to prescribe is not my own personal opinion. It helps ward off having patients take it personally.