The Back Surgeon
Grifters take advantage of people by exploiting information their victims do not have. In medicine they do it by not having the information themselves.
Fiction under construction
After the life-ruining crimes committed against Aaron in a hospital, but before he got diagnoses of the injuries, and before he understood it was nearly impossible to get those, and before he was sued for complaining about it, his father decided to get an operation. Considering the family’s history with healthcare, what the family would think about this was known. When Aaron’s mother told him about it, his first question was:
“I asked him that too.”
His father’s back problems were small compared to his own. His father’s passion in life was tennis, and his back was no problem when he was playing tennis. Second only to tennis was his passion for golf. How bad could the problem be if it didn’t bother him when he played golf?
“It hurts when I drive. It hurts when I sleep,” his father said.
“Get rid of your car and get rid of your bed.”
“What do you mean?”
Aaron knew his father knew what he meant. This was the way his father responded when discussion was useless. His father knew that Aaron drove a van, rather than a car, in order to be able to sit up straight and that Aaron slept on the floor, rather than a bed, in order to have the kind of support under his back that kept it from hurting.
“Get rid of your car, you’ll get rid of your back problem. At least most people will. Surgeons earn their livings by operating. That inclines them to believe that an operation is the best thing for you.” He once had asked an orthopedic surgeon he’d known socially why he had bought a full-size van when he had no kids, had nothing to haul and didn’t even do yard work. The surgeon said he decided he should practice what he preached. Everyday he told people, “Get rid of your car and you’ll get rid of your back problem.” The surgeon’s back didn’t hurt, but he didn’t want it to. So Aaron tried it. He bought a van. His car turned out to have been the last link in the chain of things hurting his back. The reduction in daily pain was noticeable in about a week. He was ecstatic finally to have figured this out. None of the orthopedic surgeons he went to as a patient had told him about this. He’d wondered why they hadn’t. If they themselves hadn’t known, why they hadn’t they?
Aaron had spent years battling the healthcare system trying to get someone to pay attention to his back. The story of that is of a lumbering machine working with a cookie cutter’s indifference to problems that did not fit its cutter. The errors and indifferences with which his case had been handled caused him to question the system. He tried to find information on how well such a system was serving its other constituents. In the end he wondered if it’s real constituents weren’t doctors.
“Dad. Most people who get back surgery are not improved by it. An unfortunately large percentage are made worse. It’s not a good risk.”
“Huh” from his father was the same as the previous “What do you mean.” It meant his father had heard but was not going to consider what he had heard. Aaron, as usual, responded anyway, “It’s not a good risk. Most people are not improved and many are made worse by back surgery.”
“I trust this doctor.”
“Doctors are in the business of gaining your trust. Appearing trustworthy and competent is how they earn their livings.”
“He says he does this operation all the time. It is cut and dried. He gets good results.”
“All doctors say that.”
“But I believe him.”
“I can see that.”
“How can you think he would be lying?”
“I didn’t say he was lying.”
“What reason would he have to lie to me?”
“I’m more concerned about how he might be lying to himself.”
“He makes his living by doing operations. Not by figuring out whether they are the best thing for his patients.”
“I don’t believe he’d do an unnecessary operation.”
“I’m sure he doesn’t either. That doesn’t mean he doesn’t do them.”
“You haven’t even met him.”
“You want me to meet him?”
“What do you mean?”
“You want me to come to an appointment with you?”
“Make an appointment. I’ll come.”
“You can’t make an appointment with a doctor to question him.”
Aaron’s mother was not in favor of the back surgery either and goaded his father into making an appointment at which Aaron could meet the surgeon. She said, “What could it hurt? This is your son. He’s concerned about you. Let him help. Let your family look out for you. It’s not as though the doctor isn’t getting paid for the appointment.”
So Aaron went to yet another doctor’s office to see yet another doctor. This one resented having to explain himself to a patient’s son. He was polite, but removed and cold. He was the expert. He was the authority. What did this kid know? The doctor explained about disks and ruptures and bulges. None of this was new to Aaron. Aaron had taken notes during such appointments for his own back in the past and then gone to a medical library to read more about it. He had talked to nurses, looked at models of spines, and spent considerable time learning about his own back. He already knew more than this surgeon was explaining. When the surgeon finished, Aaron said that according to the popular press back surgery is a bad risk.
The doctor said thousands of these operations were done every year. It was routine. Aaron said that according to the lay press most people who get back surgery are not improved by it and that many are made worse by it. The odds of getting better after back surgery were not good. Dr. Aknos related statistics on the high success rate of this particular operation. Aaron told him that one always hears statistics of high success rates from the surgeons who perform the surgeries, but completely different numbers from surgeons who don’t. Aaron said all this as politely and humbly as a child concerned for his father could. This particular surgeon did nothing to charm or humor him back. This surgeon directed his answers to Aaron’s father as though to say, “Your son is a lost cause. I hope you can see reason.”
Aaron found himself wondering why he had imagined that visiting the surgeon could be anything other than a waste of time. Surgeons are not dispassionate observers of what they are selling. If Aaron had been buying an appliance, he would have been able to gather data and information on it that would help him evaluate it. No such information was available for surgeons and surgeries. With medicine, one was rolling dice and hoping for the best.
Aaron was unable to persuade his father not to get the operation.
After the operation, while still in the hospital, Aaron’s father needed help with things. He fumbled a lot. He was unable to sign his name on a form, but they told him just to make whatever scratch he could and that would be acceptable. No one seemed to find anything disturbing about this.
After a couple of weeks, his father still could not sign his name. At a follow-up visit to the surgeon his father mentioned problems with his right hand and arm. He’d lost more than half the use of his right hand. The surgeon said it would clear up. A couple of months after the operation his father went to the surgeon again to say that it had not cleared up. He no longer could play tennis. He no longer could play golf. He had difficulty driving. He could not even sign his name.
The surgeon said that he sees that all the time and it is a result of the injury, not the operation. When his father related that to Aaron, Aaron said, “On your way into that operating room you signed forms, didn’t you?”
“But on your way out you couldn’t and never were able to again. For five or six years you had that back problem without it effecting your ability to play tennis or drive or sign a form. But from the moment of the operation onward, you no longer could sign your name.”
His father turned to his mother and said, “Aaron says that on my way into the operation I could sign my name, but on the way out I couldn’t.” His mother said, “I heard him.”
His parents, like most people, believed what authorities told them. The doctor had issued an edict and they believed it the same way they believed religious leaders, school teachers, plumbers and all the other authority figures on whom they relied. And like almost all other patients, it did not cross their minds to complain, let alone sue.
But Aaron was in the business of evaluating the performance of licensed professionals. For a living he investigated securities brokers. As he watched his father’s life grind on miserably with his ability to work severely handicapped and without the chief joys he used to have, Aaron wanted to know more about the performance of the specific licensed professional who had done this to his father – the doctor who “sees this all the time,” the doctor who created the official record of the operation saying that it was 100% successful with no complications.
But how do you investigate a surgeon? Medicine is a closed shop that does not collect such information, not even for its own purposes. Where could one get data about a surgeon? The only thing Aaron could think to do was follow some patients. He called private investigators, names picked from the yellow pages, to ask questions about what kinds of things could be investigated, even saying, “If we just could monitor who visited his office . . .” The cost of having someone monitor the comings and goings of all the cars in a parking lot, even though it was a small parking lot, were prohibitive. Some suggested that Aaron sit in a car and watch the parking lot himself, but ever since he had been assaulted in a hospital, sitting like that for any period of time was painful, and possibly injurious for all he knew. He hadn’t been able to get anyone to diagnose the injuries to tell him.
Finally, one investigator, after hearing “If we could just monitor who visited his office” mentioned “surveillance vehicle.” Aaron had never heard of one. They were not used in Aaron’s work. This private investigator had one. Rather than pay a person by the hour to watch, park an empty drone vehicle in line of site of the doctor’s office. Motion detectors would turn on a camcorder to videotape every person who went in and out of the doctor’s office and capture the license plate numbers on their cars.
It was a fraction of the cost of the other options, but it still added up. He made a deal with the investigator. When no one else was contracting to use the surveillance vehicle, it would watch the surgeon’s office. Since that would keep the vehicle constantly working with no downtime, he gave it to Aaron for half price. Aaron contracted to use it for a month. Since he had become a fulltime patient himself, he had no money coming in, but he needed to know what was going on in medicine badly enough to sacrifice whatever he could to find out.
As time wore on the private investigator got to know Aaron and his cause better. He took pity on him and gave him some additional help. Aaron needed to have a name and address and phone number for every license plate number. Usually there is an additional charge for each of those, but this private investigator let Aaron go through the video tapes himself to cull out the license plate numbers. The investigator then gave Aaron the access necessary to search for the names associated with them. He wouldn’t have done this for anybody else, but Aaron, after all, was an investigator in a different field, and was doing research that was in the public’s interest. And the investigator was right there next to him at the next desk while Aaron was doing it. When the month was up, he told Aaron that he’d leave the surveillance vehicle sitting where it was until someone else needed it. Aaron got an additional three weeks for free.
Seven weeks of license plate numbers produced a list of people eighty-eight people who had back surgery with Dr. Aknos. More people than that had gone into that office. Aaron contacted all of them. Most had either seen other doctors or seen Dr. Aknos about something other than their backs. And the ones who had back surgery had had it over a wide span of time, some of them continuing to come back for help afterwards. But Aaron now knew of eighty-eight patients who had back surgery with Dr. Aknos.
Aaron called them and told them he was doing research on surgical outcomes and created profiles on them. Some had had their surgeries long ago and were back for follow-ups. Some did not get their surgeries until after he contacted them as they had been seeing him for preliminary visits. He wished he could call each of the eighty-eight every month to see how they were doing, but that would be too intrusive. He called them only once per year. This wasn’t a scientific study, but it was the best he could do.
Nineteen of them reported no significant changes in their lives after the surgery. The rest tended to discuss their lives in terms of pre-surgery and post surgery. Before the operation life had been one kind of thing. Afterwards it had been another. They did not date the change in their lives from the moment they first were injured or first started having back pain. The pain had been a problem, and had been incapacitating for some, but incapacitating in terms of discomfort, not in terms of a loss of coordination and strength. It may have hurt to sleep on a mattress before, but they still could work, even operate the tools of their trades if their work was manual. Until the surgery.
After six years of calling them once per year, out of eighty-eight patients, sixty-four no longer could engage in physical activities that previously had been normal for them, like pushing lawnmowers, riding bicycles, doing manual labor, or even just washing dishes without dropping them. Forty-two had lost their careers. Twenty-three had gotten divorced. Eleven had committed suicide. Each year Aaron called them, heard the despair in their voices and recorded testimony that was increasingly worse. Aaron asked them to get their medical records and send copies to him. He researched the kinds of surgeries they had. He read the assessments written by the surgeon – complete success with no complications. Even the records of the follow-up visits did not record the problems the patients were reporting. “Returned with questions” covered a visit from someone whose entire life had become pain avoidance since that surgery, now spending 24 hours a day lying in a stupor in front of a television on which he barely could focus because of pain medication. Through it all none of them filed a complaint or called a lawyer. Most believed the doctors who told them the surgeries had been successful. Quietly they resigned themselves to sad ends, just as his father had.
Aaron wished his study could be more scientific. There was a bias in the fact that patients for whom things had not gone well would be more likely to return for follow-up visits and therefore be more likely to end up in his study. This study had no way to measure whether he had happened on a blip of unusually severe cases. And he was not a dispassionate observer as he followed their cases. But why was he the only one following up with them? Why was no one else aware of what he found? It was not as though these patients had not sought medical help over and over again since their operations. Most had been to other doctors. As Aaron examined the records from those other doctors, none of them had recorded the statements the patients made about the surgery being the watershed after which everything was much worse. Many had said that to the surgeon too. The patients were surprised that none of the physicians had reported their statements about this. Why was this not recorded anywhere?
According to the United Nation’s World Health Organization, an average of one in ten hospital patients world-wide suffers preventable harm having the potential to result in disability or death. The numbers are staggering, but it is not in the interest of people in medicine to be aware of that. So they aren’t. Instead, they record only the positive information. It is not in their interest to create accurate records. The psychology of care giving and self interest are not recognized as influences on perception in the health care community. The community of doctors collectively agrees on a version of reality that is at odds with the experience of patients.
Dr. Aknos was board certified and well-trained. As his practice grew, he grew to believe that which would be good for himself and his practice, rather than what would be good for his patients. He does not believe that he is not reporting negative information. He believes that there is no negative information to report. His surgical team believes that too. So do the physicians who routinely refer patients to him. Dr. Aknos does more harm than good, but the way he and the rest of the medical community view their experience is through a fog of self-serving delusion. Information that does not contribute to their self interest is not recognized and is not recorded.
There was a time in the tobacco industry when it was believed that health benefits accrued from smoking. The medical community thinks about itself no more lucidly. Problems in medicine that are more dangerous than tobacco are hidden by recording only the positive numbers. Outcomes that are so dramatically bad as to be impossible to sweep away quietly are hidden under the rationalization that “you have to protect yourself from lawsuits.” Unsafe practices and operators endure decade after decade.
Aaron’s dynamic, energetic father’s schedule always had been crowded with work and family and friends and sports. Now his father could not engage in the sports, had difficulty with work, and was out of the loop with his friends. He wasn’t walking the links or helping organize the tournaments. Instead he was having to learn how to scratch some semblance of his signature with two hands holding the pen. And he believed the pronouncements of the surgeon who “sees this all the time” without suspecting that seeing this all the time might mean something other than what the surgeon self-servingly chooses to believe.
Aaron still was naïve enough to imagine that the surgeon would want to learn what Aaron had learned. Something about the surgeries must not be right or the outcomes would not be this bad. The surgeon would want to know that, wouldn’t he? It wasn’t a scientific study, but twenty-three divorces and eleven suicides in a group of only eighty-eight? He had witnessed his own father’s experience. He had spoken to these other families every year. He had heard their stories about trying to adjust to the incapacities that had their onsets at the time of their surgeries. He had spoken to spouses and children and heard their tones change as their families deteriorated. Surely the surgeon would want to know.
He did not call the hospital to tell them about what he had found. He had called St. Virgin about his own case previously to ask how to complain about the crime an angry surgeon committed against him. Their response had been, “He wouldn’t do that.” They would not let him file the complaint. So why call the hospital to inform them of this? Instead he mailed some of the information to the surgeon’s office.
Shortly thereafter a summons arrived. He was to appear before a judge. He was prohibited from talking to anyone ever again about “the nonsense” he was “fabricating.” He was prohibited from contacting any patients of the surgeon ever again. He was prohibited from contacting or going near the surgeon or his offices or any of his employees ever again. Lawyers for the surgeon stated emphatically that his “so called” study proved nothing. The lawyer Aaron had to hire to defend him against the threatened lawsuit charged him more per hour than the surveillance vehicle had cost per week. Financially it was ruinous. Which was the point, according to the lawyer. They wanted to make it so expensive for Aaron that he would whither. And if he didn’t whither, he could be put in jail if he “defamed” the doctor but did not have enough assets to compensate the doctor for his pain. Aaron had to sign an agreement saying he would not complain to the hospital or the state medical board or anyone else about what he had found.
There is nothing new about this. A couple of hundred years ago Dr. Benjamin Rush, one of the founding fathers of the United States of American, was a prominent physician who practiced bloodletting and mercury purges during a plague. When a man pointed out that the death rate increased wherever Rush practiced, Rush sued him and ruined him financially.
It is no different now. Dr. Aknos continued to do what paid his student loans and the salaries of his nurses and his mortgage and insurance and supported his family and maintained his standing in the community. Unfortunately, in so doing, he made it so that his patients could not.
“It is difficult to get a man to understand something when his salary depends upon his not understanding it.”
Putting work on the Internet, especially work in progress, is inviting people to look over your shoulder and comment or contribute or object or check your facts.
Persons, places, events, names and situations in this story are purely fictional. Any resemblance to actual persons, living or dead, or to their names or histories, is coincidental and unintentional.