As a neurosurgeon who focuses mainly on spine surgery, I sometimes use medical devices like pedicle screws and intervertebral cages to treat spinal instability. Watching the Netflix documentary “The Bleeding Edge” made me wonder what the misuse of medical technology means for patients and for doctors.
According to the video’s teaser, “This eye-opening look at the fast-growing medical device industry reveals how the rush to innovate can lead to devastating consequences for patients.” In a nutshell, “The Bleeding Edge” warns of the potential dangers posed by the cozy relationship between industry, doctors, and regulators.
It’s a relationship that’s hard to avoid. If asked, I would struggle to name a spine surgeon who hasn’t been to an industry-sponsored event — I certainly have — or a cardiologist who hasn’t had a drug rep buy lunch for the office at some point in their careers.
My colleagues and I would like to think we make decisions free of external influence, but we all know that human psychology is complex. Even though we consciously think we’re not being influenced, we can be subconsciously motivated by something as simple as a meal sponsored by a pharmaceutical or device company.
Conflicts of interest aren’t limited to medical devices and drugs. The health insurance industry itself, with its different tiers of reimbursement rates, can generate conflicts by influencing physicians to do more for the patients whose insurance pays more.
Watching “The Bleeding Edge” made me ask myself: What should we do about surgeons who perform operations that may not be necessary or who use medical devices motivated by inappropriate relationships with their makers? While that may not apply to the physicians in the film — most of whom seemed well-meaning — this practice goes hand in hand with the more unscrupulous tactics of the medical device industry.
Providing patients with better education is part of the solution. Patients who learn more about their conditions or treatments or recoveries, even via Google, are likely to avoid risky procedures and have better outcomes than those who don’t. That said, it is hard for patients or prospective patients to come by data on medical devices and implants, and even harder to interpret them. A surgeon with a very high complication rate, for example, can be either a careless technician or a very good one who treats patients with complex conditions.
Deep down, I believe we need a change of culture to avoid overuse of procedures or misuse of drugs and devices.
Medicine, much like the military and law enforcement, is still a hierarchical field in which many feel intimidated to speak up. While I have not observed what could be characterized as a white wall of silence, I have occasionally been surprised at how the behavior of aggressive proceduralists, who push the bounds of clinical necessity, has been excused. “He’s just old school,” I’ve heard people say, or, “I’m not sure that patient needs surgery, but her surgeon has good hands, so at least there won’t be a complication.”
Like the rest of the world, I watched in horror the trial of Larry Nassar, the team doctor for the USA Gymnastics national team and an osteopathic physician at Michigan State University, who was accused by more than 150 women and girls of sexually abusing them over the past two decades. I couldn’t help but think how many victims would have been spared had one of his medical colleagues acted on their intuition that what was occurring was not only clinically inappropriate but depraved and illegal.
“The Bleeding Edge” sensationalizes individual stories of complications from early-stage medical devices. It obscures the fact that complication rates are still quite low, and that they happen even with properly approved and vetted devices and drugs. But it does show the danger of the cavalier use of investigational medical devices.
Our colleagues mentor us, collaborate with us, teach us, and learn from us. They also need to step in when necessary. Only another orthopedic surgeon would be expected to possess the contextual knowledge to question whether a colleague chose a specific hip implant based on the strength of scientific evidence, or simply because he or she has an inappropriate connection with its maker.
It took cardiologists to blow the whistle on a cardiology group at St. Joseph’s Hospital in Lexington, Ky., which was performing cardiovascular procedures on Medicare patients who didn’t need them.
Better oversight won’t require hospital communities to resemble something out of “The Handmaid’s Tale,” in which people are looking to turn in others to the authorities for minor infractions. Most physicians — most people for that matter — know when something is amiss.
To avoid the kind of dystopia foreshadowed by “The Bleeding Edge,” one in which people can no longer trust their doctors, physicians must act decisively when they identify the rare outlier in their midst. To do anything less would risk our credibility. Worse still, it could risk the lives of the people we took an oath not to harm.
Erich Anderer, M.D., is a neurosurgeon in New York City.