Recently, I had a consultation with a pain management physician who has been practicing for five years and started his own physician-owned private practice. I will refer to this physician as Dr. Smith. I am going to use this experience to explore the ethical and financial implications of Dr. Smith’s actions and why pain management physicians should commit to competence on CSF leaks.
What Happened?
Dr. Smith had initially answered my questions correctly via email on how to patch a thoracic spinal leak–looking up the American Society of Anesthesiologists (ASA) best practices–which the majority of the thousands of anesthesiologists I have interviewed fail to do even that as the bare minimum. I have gotten some very strange responses which have included an offer to intentionally inject blood products into my spinal fluid (hello, chemical meningitis!).
With Dr. Smith, I requested a telehealth-based consultation and was more than happy to pay $250 cash for the convenience as I have a packed work schedule.
His physician-owned practice apparently had been founded in 2022, and I could tell the office was desperate for patients as his staff tried to shuffle me in the same week for an appointment. Sometimes, this can end up being a good thing, or sometimes, this indicates a problem with poor patient retention.
During the telehealth, Dr. Smith was able to answer many of my questions although there were a few red flags. One included his insistence that he had never given any patient a spinal leak from an epidural.
Statistically, this is improbable as one of the most conservative estimates of accidental punctures during epidural injections is 1.5 percent. Looking up Medicare numbers alone on many pain management anesthesiologists, readers can see that these physicians often perform more than 100 interventional spine procedures per year. Speaking as far as statistical probability, either Dr. Smith had not given up to 100 interventional spine procedures in his five-year practice after fellowship or he had failed to recognize that he had given a patient a leak.
Whenever a physician boasts to me that he has never given a patient a spinal leak, what I take from this is that he failed to recognize when he did give a leak. Mistakes happen. Thankfully, spinal leaks can be fixed easily with competent and correct care. But are these physicians owning up to their mistakes? Are they recognizing and fixing their mistakes? Obviously not in these cases where they claim to have never caused an epidural leak.
During the telehealth with Dr. Smith, I could tell that he was struggling to understand my case in full and that he did not fully understand the situation nor did he believe me as a woman explaining what had happened. In contrast, he kept insisting that he could perform a thoracic blood patch. He required me to provide more documentation from neurology to reassure him as he was unable to recognize a classic spinal leak case on sight.
As the days went by, I began to understand why his office clearly lacked a booked schedule and ostensibly also lacked patients. Dr. Smith’s apathetic personality shone through and was matched by the apathetic personalities of his staff. There was immense disorganization and no follow-up. There was no transparency on what my patient care plan was and no communication.
There also were no visit notes.
I had to keep pressing the office for access to the portal where I found a spinal CSF leak diagnosis alongside a random chronic pain diagnosis with no explanation.
I finally set an ultimatum on my need for my visit notes as part of the service I had paid for and instantly my notes were released after days of my being ignored. These notes were followed by a rambling five-paragraph email from the disorganized office manager telling me not to use assertive wording with her nor to make “threats.” Apparently, asking for adherence to medical records laws is making threats. This is yet another case of where being assertive as a woman about my healthcare is interpreted in an emotional way. This rambling email was followed by a minute-long rambling voicemail by the office manager demanding that I call her back and explain what I meant about the lack of professionalism and proactive communication at their office.
Not feeling like offering a free consultation, I ignored her and scoured the notes from the office visit, evaluating Dr. Smith’s competence. I always conduct what I call the notes test where I assess for competence and bias.
Dr. Smith had clearly gone over all of my previous records in detail but his notes meandered in the classic way of a physician struggling to make sense of what he was reading. He copied cherry-picked sentences from my past medical records in a way that I have seen both as an educator and as a patient when the student does not understand the material well enough to write original material.
In a misogynistic move, he listed anxiety first in my list of symptoms. He wrote that I had an uncommon presentation due to the fact that I have myoclonic epilepsy and secondary autonomic dysfunction as part of my spinal leak in addition to my positional headache. In fact, both of these are well-documented issues with movement disorders secondary to a spontaneous leak and CSF volume changes secondary to all types of leaks potentially causing nonconvulsive status epilepticus. Positional vital signs are a well-known sign of a medical injury CSF leak. For a spontaneous leak, "it is difficult to differentiate POTS from spontaneous intracranial hypotension (SIH), which may show positional tachycardia to compensate for intracranial hypotension."
Dr. Smith then included a disparaging comment about one of my past pain management physicians diagnosing me with a spinal leak as if Dr. Smith felt that doing so was not a possibility. This seemed to be more of a reflection of Dr. Smith’s lack of capability as I continued to read the notes. Diagnosing a leak certainly was not a possibility for Dr. Smith as he was failing to see a clear-cut case directly in front of him.
Postulating outside his scope, Dr. Smith attempted to use my opening pressure of 17 (normal range: 5-25) against me as a sign that I did not have a spinal leak and therefore something else neurological must be happening in my body. Of course, as is commonly referenced in literature, many patients with spinal leaks confirmed on imaging have normal opening pressure. In fact, less than a third of patients with spontaneous leaks have low pressure. This means that more than two-thirds of patients with spontaneous leaks will have normal or even high pressure. I have normal pressure.
The famous pioneer in spinal CSF leak research, Dr. Mokri, hypothesized that intracranial hypovolemia (low volume of CSF) is the commonality and not intracranial hypotension (low pressure). In Dr. Mokri’s logical flow, all patients with a spinal leak will have a low volume of CSF in their heads but only some of these patients with low volumes of CSF will have this manifest as low pressure. This is simply due to diversity in biology in the compensatory mechanisms for how the human body reacts to low CSF volume.
Dr. Smith continued to hold fast to his assertion both verbally in the telehealth and in his notes that he was more than capable of providing a thoracic blood patch. Clearly, if I had a spinal leak that needed a thoracic blood patch, he would have to perform. If he created a case against me and confounded the issue, then he would not have to perform.
And therein lay the dilemma.
Dr. Smith had admitted himself that he had not performed any blood patches in private practice and had only performed a few during his training. I actually had already reached out to the department where he completed his fellowship and knew that the department had reported to me that none of the attending physicians (the instructors) knew how to complete a thoracic blood patch at that university.
As I have covered in previous articles, the content outline for the pain management board exam by the American Board of Anesthesiology (ABA) does not address epidural blood patches nor is there any proof that board-certified physicians are assessed on their ability to provide lumbar, thoracic, and cervical epidural blood patches.
An Ethical Perspective
So the following questions arise as far as ethics:
- Was Dr. Smith desperately trying to preserve his ego by insisting that he somehow knew how to do a procedure on which he was not trained for a diagnosis which he lacked the ability to recognize?
- Did he intentionally confound my notes and prevent my access to care to try to cover for the fact that he was not confident in his ability to provide an epidural blood patch and instead try to go silent instead of admitting lack of ability?
- Is it Dr. Smith’s responsibility to learn a much-needed procedure and to be able to identify the clinical presentation of this common condition if information is not being taught in the US healthcare education system?
- Some physicians seek out additional training on epidural blood patches beyond a single fellowship to gain clinical experience that they were never afforded initially. Was it Dr. Smith’s responsibility to gain clinical experience in addition to theoretical knowledge if his fellowship program never taught him how to administer blood patches?
A Business Perspective
As far as a business perspective on this issue, I work behind the scenes as a business development and marketing consultant for medical practices. I also am heavily involved in healthcare accessibility projects with an emphasis on the need for improvement in healthcare education for a medical injury that impacts more than 2.3 million Americans every year. There is both an ethical duty to provide competent care as well as a business opportunity.
From a business perspective, I often re-work business models to adapt healthcare services to meet market demands by patients and increase both patient outcomes and practice profitability. Committing to competence in order to offer a much-needed service increases healthcare accessibility, increases patient retention, and increases positive word-of-mouth advertising, the latter of which reduces marketing and patient acquisition costs.
If Dr. Smith had committed to increasing competence on his spinal leak knowledge, he would have tapped into a massive market. Epidural blood patches are highly affordable when paying cash, and some anesthesiologists have started offering cash-based services only for spinal leak care as health insurance reimbursement rates do not make epidural blood patches worth physicians’ time. Working out a business model for the high demand of correct blood patches and telehealth-based consultations to work around our patient population’s low mobility levels, I have calculated an increase of a gross of $100,000 per month for a single-physician practice.
Dr. Smith could have begun his commitment to competence by believing patients–even if they are women. He could have asked me more questions and researched my symptoms as common for a leak. I did not reveal to him that I provide healthcare education materials to resident physicians on spinal leaks that review patient experiences and the relevant literature. But I’m an open book and a fount of knowledge during consultations. Additionally, I did not reveal that I am an influencer in the spinal leak space and that competent and correct care in my case would have resulted in an endorsement from me as a trusted voice on spinal leaks, healthcare accessibility, and the patient experience–an endorsement from me would have been followed by thousands of patients rushing to seek care from him.
Instead, Dr. Smith chose to close that book. Preserving his ego was more important than listening to women patients and expanding his knowledge.
Based on the poor management of his office and poor communication around patient care planning, I expect that he will not stay in business for long based on what I have seen in working with healthcare-adjacent businesses in the finance industry and watching medical office after medical office go under primarily due to one fact: failure to listen to the patient.
