Why Your Doctor Doesn't Trust Data

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This is clinical research: Take a hundred people with a certain injury, say a rotator cuff tear. Treat them the same way with the same operation, then bring them back a year later to see how they turned out.

That's pretty much how we officially get the information we need to answer questions like "How well does the surgery for torn rotator cuffs work?" It's sometimes how we decide to start doing new operations in favor of old ones, or even not to do any operation at all. (Remember, Boomers, how all your friends had their tonsils out when you were a kid? But hardly any kids go through that surgical rite today today. Clinical research said so many tonsillectomies just weren't necessary.)

All sorts of embarassing facts turn up in clinical research. The rotator cuff study found that patients on Workers' Compensation had the surgery, got better and returned to work only 42% of the time versus 94% for those not on Worker's Comp. How do we explain the fact that the same surgery "works" less than half the time if you're on Comp? Would you keep working if you had an injury that could set you free from your job but still get you paid? Maybe you would, but some patients are completely frank about not wanting to go back, ever. (See the top 10 medical breakthroughs of 2008.)

The ethics of this get sticky for doctors. We can't tell a patient "I know you're faking" but we always do.

Take the case of Chester. He's an undercover cop who fell during a chase and hurt his shoulder. He came in through Emergency — no broken bones but in severe pain. One of the problems we face with shoulders is that the tissue we have to repair can be weak or brittle from disuse; even when sewn back up it can rip again because of this. Chester's cuff tissue was thick and strong — freshly ripped off the bone. Put it back and he could certainly return to police work. (See the 10 most common hospital mishaps.)

After the operation Chester was a great patient. He did his exercises, drove himself to the office for his follow-ups, got back full motion and was making way above average progress. He was off pain meds and — an important milestone with shoulders — was able to sleep through the night. At four weeks I got a call from his police surgeon — the doctor who officially clears policemen for return to work. He wanted to know if Chester could just come back to work the phones. "Nothing more than desk work, but I need it in writing, from you.” He faxed over the form and I checked off "light duty" on his activity sheet. That was on a Tuesday. (See the Year in Health, from A to Z.)

Wednesday morning I came out of my first case to find three messages marked urgent taped to the door of the surgeons' locker room. Chester, his mother and his police surgeon all needed calls.

"They came in here going crazy," was the first thing my secretary said. "His mother says you're trying to kill him. They're calling the Board of Health on you.”

So Wednesday afternoon, Chester was back in the office. This time his mother drove. I closed the door of the exam room.

"What's wrong?" I asked.

"It's not fair,” Chester answered. “My Seargent had the same operation and he got six months off. Do you know what that desk work is like? I can't pick up those phones, can't write in those notebooks. Oh, and I'm in constant pain.”

"But Chester, it's your left arm and they know you're right-handed. And the physical therapy notes say you're doing thirty reps with five pounds."

"But the pain..." Chester persisted.

There was no reason to believe that Chester's shoulder was any different from the way it was yesterday. But I knew the pickle I was in. You can't argue with the complaint of pain. I realized how utterly impossible it would be to get him back to work before he completed the time off that he thought he had coming. I called the police surgeon.

"...and given the multifactorial nature of his pain...enviornmental stressors in the workplace...and the mounting dysphoria associated with the percieved functional deficit..." The police surgeon mercifully cut me off.

"Just give it to me in writing," he said.

Chester did shave his time off a little, returning to light duty at four months and to full duty at six. I think it was actually the gang back at the gym who lured him back. Six months, exactly his expectation. It's hard to argue with clinical research.

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See the top 10 scientific discoveries of 2008.